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THE  PRACTICE 


Dental  Medicine. 


BY 


GEORGE  F.  EAMES,  M.D.,  D.D.S., 

Professor  of  Pathology  and  Therapeutics  in  Boston  Dental  College  ;  Member  of  the 

Massachusetts  Medical  Society,  and  of  the  American  Medical  Association  ; 

Ex-President  of  the  Massachusetts  Dental  Society  ;  Member  of  the 

American  Academ}^  of  Dental  Science  ;  Honorary  Member 

of  the  Maine  Dental  Society,  etc. 


CONTAINING  THIRTY-EIGHT  ENGRAVINGS  AND 
THREE  COLORED  PLATES. 


PHILADELPHIA: 

THE  S.  S.  WHITE  DENTAL  I\IFG.  CO. 

LONDON: 

CLAUDIUS  ASH  &  SONS,  Limited. 

iSgg. 


'KK30 


Copyright  1S99,  by  George  F.  Eames. 
Entered  at  Stationers'  Hall,  London. 


en 

CO 


TO 


GEORGE  W.   STODDARD,  D.D.S., 

THIS    WORK    IS 

DEDICATED, 

IN  ADMIRATION  OF  HIS   MECHANICAL  SKILL  AND  TEACHING 
ABILITY,   AND    IN    GRATEFUL  REMEMBRANCE  OF  HIS 
KINDLY   ENCOURAGEMENT   AND    WISE    COUN- 
SEL   DURING   A   PUPILAGE  FOLLOWED 
BY    A    FRIENDSHIP    OF    OVER 
TWENTY   YEARS, 


BY  HIS  FRIEND, 

THE  A  UTHOR. 


Digitized  by  tine  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/practiceofdentalOOeame 


PREFACE. 


The  object  of  the  following  work  is  to  supply  a  need  which  has 
existed  for  some  time.  No  text-book  has  covered  the  subjects 
herein  proposed,  and  such  technical  literature  as  may  be  found  in 
books  and  journals  is  largely  unclassified  as  to  etiology,  pathology, 
diagnosis,  treatment,  etc.,  and  is  thus  unavailable  for  handy  refer- 
ence or  systematic  study. 

A  still  greater  need,  more  and  more  in  evidence  as  the  demand 
for  a  higher  education  for  dentists  grows  stronger  and  the  neces- 
sity for  a  more  general  knowledge  of  medicine  on  their  part 
becomes  apparent,  is  for  an  explanation  of  the  significance  of  dental 
and  oral  relations  to  certain  general  pathological  conditions.  This 
need  is  not  supplied  by  medical  colleges,  for  in  these  the  teaching 
is  not  adapted  to  dental  practice  and  the  dental  relations  to  the 
various  subjects  taught  are  not  elucidated.  It  would  seem  that 
the  time  has  come  wdien  the  dentist  should  possess  formulated 
rules  and  methods  of  practice  in  the  medical  treatment  of  dental 
cases. 

The  effects  of  certain  constitutional  disorders  upon  the  teeth 
and  other  oral  structures  are  being  better  understood  as  time  goes 
on,  and  the  influence  of  local  pathological  conditions  in  the  mouth 
upon  other  organs  and  tissues  are  in  like  manner  being  better 
comprehended;  therefore  the  advanced  teaching  of  to-day  should 
give  these  subjects  the  consideration  wdiich  their  importance 
demands. 


VI  PREFACE. 

This  book  is  an  endeavor  to  accomplish  the  task  thus  indicated; 
and  if,  in  certain  instances,  the  writer  has  failed  to  reach  the 
standard  which  may  be  demanded  by  those  qualified  to  criticise, 
he  asks  indulgence,  hoping  to  profit  by  intelligent  criticism. 

Grateful  acknowledgment  is  made  to  Dr.  G.  V.  Black  and  to 
Lea  Brothers  &  Co.  for  permission  to  use  cuts  and  various  por- 
tions of  the  text  from  the  "American  System  of  Dentistry." 

The  writer  is  deeply  indebted  to  Prof.  Edward  C.  Kirk  for  his 
able  criticism  and  invaluable  suggestions,  which  have  greatly 
enhanced  the  value  of  the  work. 

To  Prof.  John  A.  Follett  are  due  the  warmest  thanks  for  the 
many  evening  hours  of  kindly  counsel  and  criticism  which  he  so 
generously  gave  for  the  writer's  benefit. 

G.  F.  E. 

Boston,  March  i,  1899. 


CONTENTS. 


Introductory. 

CHAPTER  I.  PAGE 

General  Considerations  in  Pathology I 

CHAPTER  II. 
The  Inflammatory  Process  in  General 4 

Diverse  Conditions  presenting  to  the  Dental  Practitioner. 

CHAPTER  III. 
Syncope   20 

CHAPTER  IV. 
Hysteria    21 

CHAPTER  V. 
Neuralgia  27 

CHAPTER  VI. 

Consideration  of  Subjects  Involved  in  the  Administration  of 
Anesthetic  Agents 33 

CHAPTER  VII. 
Menstruation;  Pregnancy 51 

CHAPTER  VIII. 
Hemorrhage   54 

CHAPTER  IX. 
Constipation    61 

CHAPTER  X. 

Swallowing  Plates  and  Other  Foreign  Bodies 62 

vii 


Vlll  CONTENTS. 

General  Diseases  having  Local  Expression  in  the  Mouth. 

CHAPTER  XL  page 

Stomatitis  67 

CHAPTER  XII. 
Diphtheria  83 

CHAPTER  XIII. 
Scurvy  85 

CHAPTER  XIV. 
Rhachitis   91 

CHAPTER  XV. 
Scrofula .' 92 

CHAPTER  XVI. 
Chancroid,  or  Soft  Chancre 94 

CHAPTER  XVII. 
Syphilis 95 

CHAPTER  XVIII. 
Rheumatism    , 98 

CHAPTER  XIX. 
Dyspepsia 100 

CHAPTER  XX. 
Tetanus    103 

Local  Diseases  affecting  the  Soft  Tissues  of  the  Mouth. 

CHAPTER  XXI. 
Gingivitis    109 

CHAPTER  XXII. 
Pyorrhea  Alveolaris no 

CHAPTER  XXIII. 
Phagedenic    Pericementitis 122 

CHAPTER  XXIV. 
Difficult  Dentition 126 

CHAPTER  XXV. 
Salivary  Fistula I35 

CHAPTER  XXVI. 
Salivation   138 

CHAPTER  XXVII. 
Ranula   140 


CONTENTS.  IX 

Local  Diseases  affectingthe  Dental  and  Surrounding  Bony  Tissues. 

CHAPTER  XXVIII.  page 

Dental   Caries 144 

CHAPTER  XXIX. 
Hypersensitive  Dentin. 153 

CHAPTER  XXX. 
Hyperemia  of  the  Dental  Pulp 161 

CHAPTER  XXXI. 
Pulpitis — x\cute;   Chronic 165 

CHAPTER  XXXII. 
Suppuration  and  Abscess  of  the  Dental  Pulp 170 

•     CHAPTER  XXXIII. 
Pericementitis    174 

CHAPTER  XXXIV. 
Dento-Alveolar   Abscess 178 

CHAPTER  XXXV. 
Dental  Erosion 182 

CHAPTER  XXXVI. 
Abrasion    187 

CHAPTER  XXXVII. 
Hypercementosis  188 

CHAPTER  XXXVIII. 
Secondary  Dentin 192 

CHAPTER  XXXIX. 
Pulp   Nodules 193 

CHAPTER  XL. 
Necrosis  195 

CHAPTER  XLI. 
Ankylosis  of  the  Jaw 206 


X  CONTENTS. 

Diseases  affecting  the  Adnexa  of  the  Mouth. 

CHAPTER  XLII.  page 

Empyema  and  Other  Pathological  Conditions  of  the  Maxillary 
Sinus    207 

CHAPTER  XLin. 
Hypertrophy  of  the  Faucial  Tonsils 214 

CHAPTER  XLIV. 
Hypertrophy  of  Adenoid  Tissue  in  the  Post-Nasal  Space 215 

CHAPTER  XLV. 

The  Relation  of  Adenoid  Vegetations  to  Irregularities  of  the 
Teeth  and  Associate  Parts 221 


INDEX 229 


THE  PRACTICE  OF  DENTAL  MEDICINE. 


INTRODUCTORY. 


CHAPTER    I. 
GENERAL  CONSIDERATIONS  IN  PATHOLOGY. 

All  branches  of  medical  science  have  been  formulated,  their 
sphere  of  usefulness  being  found  in  the  only  too  frequent  tendency 
of  the  body,  either  by  traumatism  or  disease,  to  depart  from  the 
normal  or  healthy  condition.  This  departure  from  a  state  of 
health  inaugurates  what  is  known  as  a  pathological  condition,  or 
state  of  disease. 

Pathological  conditions  may  assume  a  great  variety  of  forms, 
each  presenting  certain  characteristics  peculiar  to  itself,  conse- 
quently each  pathological  condition  thus  marked  off  is  given  a 
name  by  which  it  is  designated,  but  the  name  of  the  disease  is  only 
ascertained  by  a  study  of  its  characteristic  expressions,  or  symp- 
toms. 

Symptomatology. — There  are  many  different  diseases,  each  with 
its  own  set  of  symptoms,  yet  the  individual  symptoms  of  one  may 
not  differ  from  those  of  any  other  disease.  Several  symptoms  of 
one  disease  therefore  may  be  found  in  another,  but  if  we  study 
these  symptoms  attentively  we  shall  notice  the  fact  that  they  are 
often  found  in  groups, — a  number  of  satellites  to  some  more 
important  symptom  which  either  is  not  found  at  all  in  other  dis- 
eases, or  has  a  different  group  of  associate  symptoms.  These 
manifestations,  symptoms,  or  expressions  of  disease  may  be  known 
to  us  in  the  following  ways:  By  physical  manipulation,  seeing, 
hearing;  and  by  those  sensations  of  which  only  the  patient  can 
tell  us. 


2  THE    PRACTICE    OF    DENTAL    MEDICINE. 

We  may  also  in  this  way  learn  the  history  of  the  disease,  which 
may  give  significance  to  the  symptoms*  and  assist  in  the  diagnosis; 
indeed,  it  is  by  means  of  the  symptoms  and  clinical  history  that  a 
diagnosis  is  formed. 

Differential  Diagnosis. — If  some  diseases  have  many  symptoms 
in  common,  how  shall  a  discrimination  be  made?  Under  such 
circumstances  it  is  customary  to  eliminate  the  symptoms  which  are 
common  to  the  group,  when  it  will  be  usually  found  that  some  one 
or  more  prominent  symptoms,  or  a  particular  combination  of 
symptoms,  connected  with  the  case  under  consideration,  mark  it 
off  from  the  others;  these  constitute  the  distinguishing  features 
upon  which  a  diagnosis  is  made. 

Influence  of  Pathological  Processes. — Diseases  in  general  usually 
follow  a  somewhat  typical  course,  nearly  always  beginning  with 
some  local  affection  or  producing  one  after  a  short  time.  At  the 
seat  of  the  disease,  abnormal  products  are,  after  a  time,  usually 
formed;  these  soon  find  their  way  through  various  channels  to 
surrounding  parts,  thence  by  the  lymph-  and  bloodvessels  into  the 
general  circulation,  thus  reaching  every  part  of  the  body  and  pro- 
ducing new  symptoms. 

The  nerves,  not  being  exempt  from  this  morbific  influence, 
cause  additional  symptomatic  sensations,  thus  exhibiting  the  won- 
derful sympatnetic  relation  of  all  parts  of  the  human  body. 

A  Knowledge  of  Minute  Physiological  and  Pathological  Processes 
as  a  Basis  of  Treatment.^To  cope  successfully  with  disease,  one 
must  not  only  possess  a  knowledge  of  the  functions  in  health,  but 
the  broadest  possible  conception  of  life  as  exhibited  in  numberless 
animal  forms  from  the  ameba  to  man;  thus,  having  an  understand- 
ing of  the  characteristics  of  the  simple  forms  under  both  normal 
and  abnormal  conditions,  it  becomes  a  comparatively  easy  task  to 
gain  a  knowledge  of  like  conditions  in  larger  and  more  complex 
forms,  which  are  only  multiplications  of  the  simpler  forms. 

The  physician  when  called  to  a  patient  first  considers  the  body 
as  a  whole,  its  position,  movement,  etc.  Then  follows  an  inspection 
of  its  parts,  as  the  tongue,  pulse,  and  skin;  special  organs  receive 
attention,  such  as  the  heart,  lungs,  and  kidneys;  the  secretions  are 
analyzed,  placed  under  the  microscope;  and  finally,  perhaps,  the 
blood-cell  itself  is  subjected  to  a  similar  analysis. 

These  blood-cells  may  be  studied  in  the  blood  of  a  frog  under 

*  The  term  "symptom"  is  intended  to  include  "piiysical  signs." 


GENERAL    CONSIDERATIONS    IN    PATHOLOGY.  3 

the  microscope.  Under  normal  conditions,  the  white  blood-cell 
may  be  seen  to  move,  throw  out  pseudopodia,  ingest  particles  of 
food,  and  assimilate  them.  If  now  a  putrescent  fluid  be  injected 
into  the  circulation  and  after  a  time  a  portion  of  blood  drawn  off,, 
an  interesting  and  wonderful  sight  presents  itself,  viz.  many  of  the 
white  cells  will  be  seen  to  contain  bacteria,  whose  presence  results 
in  various  degrees  of  injury.  Some  cells  are  found  unchanged, 
others  are  partially  destroyed,  and  some  are  dead.  If  the  cell  can 
withstand  the  noxious  influence  of  the  bacteria,  it  recovers ;  if  not, 
it  dies.  It  is  simply  a  question  of  warfare  between  the  white  blood- 
cells  and  the  bacteria.  The  victory  of  the  white  blood-cells  means 
defeat  of  the  disease  germs,  and  a  return  to  health  of  the  entire 
organism.  Such  a  study  of  these  simple  forms  gives  one  a  better 
understanding  of  the  diseases  in  which  they  play  so  strong  a  part. 

Idiosyncrasy. — Idiosyncrasy  is  a  condition  of  the  body  in  which 
food,  medicine,  or  some  other  agent  produces  an  unusual  efifect. 
This  condition  is  weir  illustrated  by  the  following  cases: 

A  man  of  intelligence,  and  in  good  health,  could  not  take  a 
teaspoonful  of  honey  without  great  swelling  of  the  face  and  neck, 
distress,  and  much  difficulty  in  breathing.  This  was  tried  in  dif- 
ferent parts  of  the  country,  and  at  intervals  of  years,  with  invariably 
the  same  effect. 

A  man,  aged  thirty-eight,  cannot  be  near  dogs  without  having 
an  attack  of  asthma. 

In  another  case,  opium  causes  catharsis  instead  of  constipation;, 
in  another,  the  mere  presence  of  fish  is  sufHcient  to  induce  urticaria. 
Very  minute  quantities  of  mercury  will,  in  some  persons,  cause 
profuse  ptyalism,  while  to  others  large  doses  may  be  given  for  a 
long  time  without  the  slightest  effect. 

Another  case  of  marked  idiosyncrasy  was  shown  in  a  man  who 
wished  to  have  a  tooth  removed.  He  was  a  fine  specimen  of 
physical  manhood,  the  last  person  in  whom  one  might  suspect  any 
physical  peculiarity.  The  administration  of  nitrous  oxid  was 
begun,  but  after  two  or  three  inhalations  he  showed  signs  of 
strangulation,  with  discoloration  of  the  face,  and  it  seemed  impossi- 
ble for  him  to  inhale  more.  Upon  repeated  attempts  the  same 
result  occurred  each  time,  though  nothing  was  amiss  with  the 
inhaler  or  with  the  anesthetic  agent.  Ether  was  substituted 
immediately  afterward  with  a  most  satisfactory  result,  the  breath- 
ing being  easy  and  natural. 


4  THE    PRACTICE    OF    DENTAL    MEDICINE. 

These  cases  should  teach  watchfulness  and  preparation  for 
possible  emergencies  that  may  arise.  The  precaution  should  be 
taken  not  to  administer  the  full  dose  of  a  powerful  drug  to  a 
patient  seen  for  the  first  time,  but  to  divide  the  dose  and  watch  its 
action. 


CHAPTER    II. 

THE  INFLAMMATORY  PROCESS  IN  GENERAL. 

The  essential  nature  of  inflammation  is  not  understood  at  the 
present  time,  therefore  the  following  definitions  simply  include  the 
most  prominent  phenomena  which  are  manifested  in  this  patho- 
logical process. 

Definition. — Inflammation  may  be  defined  as  a  pathological 
process  in  which  the  action  of  the  capillary  vessels  is  perverted, 
and  the  circulation  deranged;  these  symptoms  being  accompanied 
by  discoloration,  heat,  pain,  swelling,  and  disordered  function. 
Bland  Sutton  defines  inflammation  as  "the  method  by  which  an 
organism  attempts  to  render  inert  noxious  elements  introduced 
from  without,  or  arising  within  it."  In  Dennis'  Surgery  inflamma- 
tion is  defined  as  "the  sum  of  the  phenomena  which  take  place  in 
the  tissues  as  the  effect  of  an  injury." 

Etiology. — Causes  are:  i.  Predisposing  (a,  natural;  h,  acquired). 
2.  Exciting.  A  predisposing  cause  is  one  which  places  the  human 
system  in  a  condition  favorable  to  the  production  of  inflammation, 
without  actually  producing  it.  An  exciting  cause  is  one  which, 
either  alone  or  in  conjunction  with  the  predisposing  cause,  pro- 
duces inflammation  or  disease  immediately. 

Natural  Predisposing  Causes. — These  are  inherent  in  the 
human  system,  while  those  causes  may  be  called  "acquired"  which 
depend  upon  accidental  circumstances.  The  first  group  have 
reference  to  physical  peculiarities,  inborn  or  engrafted  into  the 
system,  which  prepare  the  way  for  an  active  disease  having  a  direct 
cause.  Among  these  physical  peculiarities  may  be  classed  the 
taint  of  syphilis,  general  debility,  plethora,  and  nervous  suscepti- 
bility. For  instance,  persons  who  have  naturally  a  large  amount 
of  blood,  or,  in  other  words,  are  plethoric,  are  especially  prone  to 


THE    INFLAMMATORY    PROCESS    IN    GENERAL.  5 

inflammation,  while  those  of  a  feeble  or  lax  constitution  are  more 
liable  to  local  congestions.  It  is  true  that  such  congestion  is  likely 
to  end  in  inflammation,  but  the  process  is  not  so  rapid  as  in  a 
plethoric  constitution. 

Age  and  Sex. — Age  and  sex  may  also  be  included  in  natural 
predisposing  causes.  At  different  stages  of  life  certain  organs  are 
especially  liable  to  inflammation.  For  example,  in  infancy  we  have 
teething  and  diarrhea;  in  childhood  the  skin,  parotid  gland,  and 
tonsils  are  peculiarly  susceptible.  Manhood  experiences  inflam- 
mation of  the  lungs,  heart,  and  genito-urinary  organs,  and  later  in 
life,  throughout  old  age,  one  is  prone  to  gout^  rheumatism,  asthma, 
hepatitis,  pleuritis,  etc. 

The  chief  tendencies  to  inflammation  which  are  determined  by 
sex  are  included  in  occupation,  dress,  exercise,  etc. 

Acquired  Predisposing  Causes. — Food,  dress,  occupation, 
climate,  and  season  may  act  as  agents  by  which  one  may  acquire 
a  predisposition  to  inflammation. 

Food. — It  is  well  known  that  the  character  of  food  has  an  influ- 
ence in  predisposing  one  to  inflammation.  Either  the  habitual  use 
of  stimulating  articles  of  diet,  and  especially  alcoholic  drink,  on  the 
one  hand,  or  an  impoverished  diet  on  the  other,  always  stands  as 
an  important  factor  to  be  taken  into  account  in  the  prognosis  of 
possible  future  inflammation. 

Dress. — The  majority  of  persons  have  yet  to  learn  how  to  dress, 
and  it  is  not  an  easy  lesson.  The  body  is  often  kept  too  warm  or 
too  cold.  The  circulation  may  be  impeded  by  tight  clothing  or 
footwear,  causing  anemia  of  the  compressed  part  and  congestion 
of  the  unrestricted  parts,  as  well  as  an  endless  train  of  consequent 
evils.  These  local  congestions  are  acquired  predisposing  causes 
of  inflammation. 

Occupation. — If  one's  occupation  is  such  that  any  organ  or  set 
of  organs  is  used  constantly,  with  the  liability  of  being  overworked, 
it  may  become  the  seat  of  chronic  inflammation,  with  acute  attacks 
from  time  to  time.  Singers  and  speakers  are  afflicted  with  inflam- 
mation of  the  larynx,  while  dentists  and  watchmakers  are  liable  to 
a  similar  condition  of  the  eyes. 

Climate. — A  change  of  climate  must  always  be  taken  into  con- 
sideration as  rendering  a  patient  more  liable  to  inflammation, 
whether  the  change  be  from  north  to  south,  or  south  to  north. 

It  is  a  matter  of  common  experience  that  it  takes  time  to 


6  THE    PRACTICE    OF    DENTAL    MEDICINE. 

become  acclimated  to  a  certain  locality,  and  to  overcome  a  prone- 
ness  to  disease  during  this  period. 

Season  has  its  influence.  In  summer  there  is  more  liability 
to  inflammation  of  the  stomach  and  bowels,  while  in  winter  the 
Schneiderian  membrane,  the  pericementum,  and  the  membrane  of 
the  throat  and  lungs  are  more  frequently  affected. 

Exciting  Causes. — The  great  variety  of  exciting  causes  of 
inflammation  may  be  divided  into  two  classes,  local  and  constitu- 
tional. As  examples  of  local  causes,  the  following  are  some  of  the 
most  common:  Heat  in  any  form  whatsoever;  caustic  substances, 
as  acids  and  alkalies;  acrid  vapors  and  secretions.  All  these  agents 
may  act  upon  the  part  so  as  either  to  impair  its  structure  and  func- 
tion or  to  destroy  the  tissue  outright.  These  local  irritants  act 
rapidly  and  may  cause  severe  local  and  constitutional  symptoms. 
Other  local  causes  acting  mechanically  are  incisions,  punctures, 
contusions,  fractures,  and  dislocations;  distensions,  as  by  gas; 
compressions,  as  by  ligatures  or  bandages;  the  presence  of  foreign 
bodies,  as  a  calculus  forming  a  ranula;  an  unerupted  tooth,  etc. 

Constitutional  causes  are  more  obscure  as  to  their  action.  A 
severe  shock  is  a  cause  often  followed  by  serious  consequences,  as 
in  case  of  a  railroad  injury  or  a  gunshot  wound,  the  victim  often 
surviving  the  first  effects  only  to  succumb  to  the  later  reaction  due 
to  shock.  Insufficient  food,  by  lowering  the  standard  of  vital 
resistance,  is  a  prolific  constitutional  cause  of  inflammation.  Ex- 
perimentation upon  animals  shows  this,  for  as  the  starvation 
process  continues  it  is  followed  by  ulceration  of  the  intestinal  tract. 
Scurvy,  as  is  well  known,  is  caused  by  a  deficiency  of  alkaline  salts 
in  the  blood,  for  which  reason  lemon-juice  is  liberally  and  effectu- 
ally used  in  such  cases. 

Varieties. — Generally  speaking,  inflammation  may  be  acute  or 
chronic;  it  may  be  further  classified  as  simple  or  traumatic,  and 
purulent  or  septic. 

The  acute  form  of  inflammation  runs  through  its  different  stages 
quickly,  each  being  distinguished  by  well-marked  symptoms,  as  in 
acute  pulpitis.  In  the  chronic  form  the  inflammatory  action  not 
only  runs  a  longer  and  more  indefinite  course,  but  is  milder  in  all 
its  symptoms.  It  may  have  a  beginning  in  this  mild  way,  often 
existing  without  being  recognized ;  usually,  however,  it  occurs  as  a 
sequence  of  the  acute  form. 

The  wound  resulting  from  an  extracted  tooth  may  be  repaired 


THE    INFLAMMATORY    PROCESS    IN    GENERAL.  / 

without  destruction  of  tissue,  the  inflammatory  process  being 
immediately  utiHzed  to  restore  the  breach  in  continuity. 

An  example  of  simple  or  traumatic  inflammation  may  be  seen 
in  the  following  imaginary  case :  A  tooth  is  extracted  for  regulat- 
ing purposes,  or  on  account  of  an  inflamed  pulp;  the  alveolo- 
dental  periosteum  and  surrounding  tissues  are  in  a  normal  condi- 
tion. The  inflammatory  process  is  begun  at  the  site  of  the  solution 
of  continuity,  and  if  the  patient  is  in  a  sound  physical  state,  i.e.  if 
there  is  no  systemic  infection  and  no  local  microbic  infection  of 
the  wound,  all  the  migratory  cells  are  immediately  devoted  to  the 
work  of  repair,  there  being  practically  no  bacteria  to  combat.  The 
inflammatory  process  is  thus  utilized  to  restore  the  breach  in  con- 
tinuity, and  this  is  its  legitimate  function. 

But  the  dreaded  microbe  may  take  advantage  of  the  following 
conditions  illustrating  septic  inflammation:  The  patient,  whose 
vitality  has  been  weakened  by  previous  disease,  has  an  acute  alveo- 
lar abscess  involving  a  tooth  nearly  destroyed  by  caries;  which 
with  the  unhygienic  condition  of  the  mouth  affords  ideal  conditions 
for  the  propagation  of  bacteria  and  their  entrance  into  the  affected 
tissues.  The  overwhelming  numbers  of  bacteria  overcome  the 
phagocytes,  which  are  converted  into  pus-cells,  and  destruction  of 
tissue  follows.  It  is  the  entrance  of  bacteria  which  does  harm;  in 
every  case  they  are  the  disturbing  element,  whose  presence  is 
abnormal  and  injurious. 

The  accumulation  of  inflammatory  products  continues  as  the 
warfare  between  phagocyte  and  bacterium  goes  on,  the  inhibition 
or  destruction  of  the  bacterium  causing  the  death  of  the  phagocyte 
and  its  conversion  into  pus.  The  accumulation  of  pus  and  its 
subsequent  degeneration  ma}-  cause  much  destruction  of  tissue  at 
the  site  of  the  local  injury,  and  poisons  generated  in  this  affected 
area  may  spread  throughout  the  system,  causing  constitutional 
symptoms,  when  final  recovery  is  a  question  of  the  chemotactic 
warfare  and  the  vitality  of  the  patient. 

Inflammation,  therefore,  must  end  either  in  health,  or  in  the 
death  of  the  part  aft'ected;  if  in  health,  the  inflammation  is  said  to 
terminate  by  resolution;  if  in  death,  by  dissolution,  ulceration,  or 
gangrene. 

Extension  of  Inflammation. — The  term  "extension"  suggests  at 
once  a  small  beginning  with  increase  in  the  severity  of  the  symp- 
toms as  well  as  in  the  amount  of  territory  invaded.     The  plain 


8  THE    PRACTICE    OF    DENTAL   MEDICINE. 

deduction  is,  therefore,  that  while  all  inflammations,  of  whatever 
character,  are  at  first  strictly  local,  they  may  afterward  spread, 
involving  large  surfaces  of  the  body  and  bringing  the  entire  system 
into  general  sympathy.  Inflammation  may  spread  from  one  part 
of  the  body  to  another  in  five  different  ways,  viz. :  By  continuity 
of  structure;  by  contiguity  of  structure;  by  means  of  the  lymphat- 
ics; through  the  agency  of  the  nervous  system;  and  by  the  blood. 
The  rapidity  with  which  inflammation  travels  from  one  part  of  the 
body  to  another  varies  greatly,  depending  upon  the  character  of 
the  irritant  and  the  structure  involved. 

Extension  by  Continuity  of  Structure. — By  this  means,, 
the  inflammatory  action,  once  begun,  passes  along  the  same  kind 
of  structure,  unhindered  by  varying  degrees  of  resistance;  for 
example,  erysipelas  of  the  skin  may  at  first  show  an  inflammatory 
surface  no  larger  than  a  finger-nail,  but  it  may  extend  over  the 
greater  part  of  the  body  in  a  few  hours. 

Extension  by  Contiguity  of  Structure. — The  word  itself 
conveys  a  very  good  idea  of  the  way  in  which  disease  spreads,  and 
may  only  be  made  clearer  by  examples  which  illustrate  it.  For 
instance,  an  inflammation  of  the  lung  may  extend  to  the  pleura 
which  covers  it  or  lies  contiguous  to  it.  Inflammation  is  often 
likely  to  spread  from  one  part  of  the  eye  to  another,  simply  for  the 
reason  that  different  parts  lie  in  close  contact  one  with  another,  as 
the  conjunctiva  and  the  sclerotic  membrane. 

Extension  by  the  Lymphatics. — The  lymphatics,  it  is  well 
known,  carry  poisonous  matters  to  their  glandular  centers,  to  be 
radiated  off  into  the  entire  system,  as  in  the  case  of  a  dental  student 
who  was  extracting  a  carious  tooth,  a  sharp  portion  of  which 
wounded  his  finger.  The  wound  itself  was  slight,  but  the  young 
man  nearly  lost  his  life  in  consequence  of  the  general  septic  poison- 
ing which  followed. 

Extension  by  the  Nervous  System. — The  nerves  seem  to 
act  as  an  agency  in  transmitting  the  inflammatory  process  in 
certain  instances,  but  the  manner  in  which  this  is  accomplished  is 
little  understood  at  the  present  day.  We  may  say  that  it  is 
through  sympathy.  And  what  is  sympathy?  We  are  scarcely 
•wiser  than  before.  We  can  only  cite  an  example  for  illustration, 
such  as  the  familiar  one  of  parotitis,  in  which  the  disease  suddenly 
leaves  the  parotid  gland  and  descends  to  the  testicle. 

Extension  by  the   Blood. — The  blood   itself   may   be   the 


:  THE    INFLAMMATORY    PROCESS    IN    GENERAL.  9 

agency  by  which  poisonous  matters  are  carried  from  one  part  to 
another.  An  inflammatory  center  may  throw  off  or  furnish  poison- 
ous particles  to  the  circulation,  which  conveys  them  to  distant  parts 
of  the  body. 

Symptoms. — The  symptoms  of  inflammation  may  be  classed  as 
(a)  local  and  (b)  constitutional. 

Local  Symptoms. — "Rubor,  calor  cum  tumore  et  dolore" 
(Celsus).  Redness,  heat,  with  swelling  and  pain,  are  still  recog- 
nized as  essential  factors  in  the  majority  of  well-pronounced  cases 
of  inflammation.  In  addition  to  these  "cardinal"  symptoms  should 
be  mentioned  with  considerable  emphasis  that  of  disordered  func- 
tion. These  symptoms  vary  in  accordance  with  the  texture  and 
function  of  the  structure  which  is  affected,  and  there  are  exceptions 
in  which  many  of  them  are  absent. 

Discoloration. — The  degree  of  redness  depends  upon  the  vascu- 
larity of  the  structure;  that  is,  in  those  parts  which  are  capable  of 
receiving  a  great  deal  of  blood,  as  the  mucous  membrane  of  the 
mouth,  the  skin,  and  cellular  tissue.  While  this  is  true,  the 
rapidity  of  the  discoloration  is  also  influenced  by  the  intensity  of 
the  inflammatory  action,  which  in  acute  cases  causes  distinct  red- 
ness in  a  very  short  time. 

Pain. — In  acute  inflammations,  pain  is  nearly  always  present  in 
proportion  to  the  intensity  of  the  morbid  action;  and  its  character,, 
as  well  as  amount,  aids  greatly  in  diagnosis  and  may  throw  much 
light  upon  the  case.  The  degree  of  pain  is  one  of  great  interest 
and  importance,  inasmuch  as  it  varies  to  so  great  an  extent  in  dif- 
ferent individuals. 

In  regard  to  the  character  of  the  pain,  it  requires  a  vocabulary 
of  adjectives  to  describe  all  the  varieties.  It  is  described  as  sharp^ 
lancinating,  stabbing,  boring,  acute,  throbbing,  sickening,  itching, 
burning,  dull,  gnawing,  scalding,  gritting,  beating,  etc.  Pain  may 
be  intermittent,  remittent,  or  paroxysmal.  It  is  usually  felt  at  the 
point  of  morbid  action,  or  at  the  point  of  greatest  intensity,  but  it 
not  uncommonly  manifests  itself  at  a  distance  from  it,  or  it  may 
travel  from  one  place  to  another.  Sometimes  pain  is  absent,, 
although  inflammation  of  a  serious  nature  is  present.  This  is  to  be 
looked  upon  as  a  dangerous  condition,  inasmuch  as  the  disease 
may  be  unnoticed  until  it  has  made  serious  progress.  On  the 
other  hand,  the  pain  may  be  so  severe  that  in  a  few  minutes  it  will 
weaken  a  previously  strong  person  so  that  he  can  scarcely  stand; 


lO  THE    PRACTICE    OF    DENTAL    MEDICINE. 

yet  it  gives  warning  of  inestimable  value,  and  furnishes  priceless 
information  in  regard  to  the  disease.  For  instance,  an  intermit- 
tent, sharp,  lancinating  pain  is  characteristic  of  neuralgia;  a  throb- 
bing pain  indicates  the  formation  of  pus. 

Posture  often  influences  pain  greatly;  thus,  an  aching  tooth 
may  be  entirely  free  from  pain  during  the  day,  but  may  ache  vio- 
lently as  soon  as  the  patient  lies  down  at  night;  an  abscess  on  the 
hand  may  cause  little  pain  while  the  member  is  elevated  in  a  sling, 
but  the  moment  it  is  lowered  the  suffering  is  aggravated  to  an 
unbearable  degree.  In  cases  of  pulpitis  the  symptoms  are  modi- 
fied by  environment,  as  stated  in  the  chapter  on  that  subject. 

Swelling. — ^With  few  exceptions,  swelling  is  present  to  some 
extent  in  all  inflammations.  The  amount  of  swelling,  as  well  as 
the  rapidity  with  which  it  progresses,  depends  upon  the  structure 
involved  and  the  character  of  the  irritant  which  produces  the 
inflammation.  The  structures  in  which  swelling  is  likely  to  be 
slight,  or  entirely  absent,  are  the  tendons,  cartilages,  bones,  vessels, 
and  nerves.  Mucous  membranes  also  suffer  little  in  this  way,  but 
tissues  lying  immediately  beneath  often  swell  to  a  considerable 
extent. 

On  the  other  hand,  the  faucial  and  pharyngeal  tonsils,  the 
glottis  and  uvula,  being  more  or  less  loosely  constructed  of  cellular 
tissue,  are  likely  to  swell  to  a  great  extent.  The  scalp  and  the  face 
are  also  examples  of  tissue  in  which  large  swellings  may  occiir,  the 
face  often  swelling  so  greatly  from  pericementitis  and  alveolar 
abscess  that  the  features  are  scarcely  recognizable.  Those  parts 
which  admit  of  large  swellings  are  also  those  which  allow  rapid 
swellings.  It  need  hardly  be  said  that  the  swelling  often  acts  in 
a  beneficial  way  in  locating  the  inflammatory  action,  and  especially 
in  mitigating  the  pain,  having  the  effect  of  depleting  the  part  in 
much  the  same  way  as  local  bleeding  or  the  action  of  a  cathartic 
on  the  bowels.  The  swelling  is  not  always  thus  beneficial,  for  if 
it  be  slower  in  progress  and  consist  of  a  hard  fibrinous  deposit,  it 
may  by  pressure  cause  stagnation  in  the  capillary  vessels  and  death 
of  the  part  affected. 

Heat. — Heat  is  a  common  factor  in  inflammation  and  forms  an 
important  aid  in  diagnosis.  In  alveolar  abscess  the  local  heat  and 
dryness  of  the  part  is  at  once  detected  by  a  touch  of  the  finger. 
If  the  morbid  action  continues,  the  entire  system  sympathizes  with 
it,  and  general  fever  is  the  result,  as  indicated  by  its  various  symp- 
toms. 


THE    INFLAMMATORY    PROCESS    IN    GENERAL.  II 

Disordered  Function. — This  symptom  is  rarely  absent,  though 
often  varying  in  degree  and  manner.  An  increase  in  sensibiHty  of 
the  part  is  one  of  the  most  common  effects  of  inflammation,  the 
sHghtest  pressure  causing  great  distress.  In  peritonitis  the  weight 
of  a  sheet  is  often  unbearable,  and  in  acute  pericementitis  the 
affected  tooth  is  excessively  painful  to  the  least  touch  of  the  finger, 
the  tongue,  or  antagonizing  tooth.  Parts  which  are  more  or  less 
insensible  to  the  touch  in  a  sound  state,  such  as  bones,  ligaments, 
and  tendons,  become  extremely  sensitive  when  they  are  inflamed, 
thus  interfering  with  their  proper  functions. 

In  inflammation  of  the  tongue  there  is  a  loss  of  the  sense  of 
taste;  in  that  of  the  nose,  a  loss  of  the  sense  of  smell.  In  laryngitis 
the  voice  is  changed  and  often  suspended  altogether.  Pericemen- 
titis interferes  with  the  function  of  mastication,  and  gastritis  hin- 
ders digestion.  The  function  of  secretion  is  nearly  always 
modified;  for  instance,  the  skin  is  dry  and  the  urine  scanty.  The 
function  of  the  absorbent  vessels  is  also  changed;  and  while 
the  absorbents  are  actively  taking  up  and  removing  affected  tissue, 
they  refuse  to  take  up  foreign  matter.  As  a  practical  illustration, 
the  dentist  does  not  expect  his  arsenical  paste  to  accomplish  the 
destruction  of  a  tooth  pulp  while  that  organ  is  the  subject  of  an 
acute  inflammatory  process. 

Constitutional  Symptoms. — If  a  local  inflammation  termi- 
nates quickly  by  resolution,  or  the  morbid  action  be  slight,  it  may 
not  be  recognized  by  the  general  system;  but  in  severe  cases,  or 
even  in  mild  ones  if  the  structure  involved  be  an  important  one,  the 
entire  organism  responds  in  sympathy  with  it;  sometimes  in  a  few 
hours  after  local  inflammation  has  been  established,  and  at  other 
times  several  days  elapse,  according  to  the  nature  of  the  exciting 
cause,  the  physical  and  mental  condition  of  the  patient,  and  the 
part  aft'ected. 

In  order  to  ascertain  the  degree  of  fever,  the  pulse*  should  be 
examined,  and  the  temperature  taken  by  means  of  a  clinical  ther- 

*  It  is  well  to  become  familiar  with  the  normal  state  of  the  pulse  in  all 
patients,  so  that  in  emergencies,  or  in  administering  anesthetics,  the 
operator  may  act  with  greater  intelligence  and  ability.  The  necessity  for 
precaution  is  obvious  when  it  is  remembered  that  the  normal  pulse  may  be 
as  low  as  forty  or  as  high  as  one  hundred  beats  per  minute. 

The  points  to  be  noticed  in  the  heart-beat  are  frequency,  hardness, 
fullness,  and  quickness.     The  average  number  of  beats  to  the  minute  in  the 


12  THE    PRACTICE    OF    DENTAL   MEDICINE. 

mometer  placed  in  the  armpit,  under  the  tongue,  in  the  rectum,  or 
in  urine  immediately  after  it  has  been  voided. 

It  will  also  be  noticed  that  the  eyes  are  unnaturally  red  and 
suffused,  the  skin  dry,  and  the  extremities  hot.  The  respirations 
are  increased  in  frequency  and  often  performed  with  difficulty. 

The  digestive  organs  suffer  also ;  the  tongue  is  red  at  the  tip  and 
edges,  dry,  tremulous,  and  usually  coated  with  a  whitish  fur,  vary- 
ing to  a  yellow  and  brown.  The  taste  is  perverted  or  wanting,  the 
saliva  scanty,  and  the  thirst  intense.  The  appetite  is  lacking  and 
often  supplanted  by  nausea  and  disgust  for  food.  The  bowels  are 
usually  constipated.  The  kidneys  give  expression  to  the  disease 
in  the  suppression  of  urine  to  a  considerable  degree,  sometimes  to 
one-half  or  one-third  the  usual  quantity.  The  color  is  changed  to 
a  deep  red,  with  more  or  less  sediment  of  a  brick  color. 

The  muscles  partake  of  the  general  discomfort,  as  indicated  by 
a  sense  of  lassitude,  stiffness  and  soreness,  with  occasional  darting 
pains. 

The  brain  shows  its  vital  connection  with  the  injured  part  by 
an  irritable  state  of  mind,  inability  to  sleep,  and  sometimes,  in 
severe  cases,  delirium. 

Intimate  Nature  of  Inflammation. — In  considering  the  finer  pro- 
cesses of  inflammation  we  look  beyond  organs  to  the  elementary 
tissues  from  which  the  inflammation  proceeds.  Let  us  first  con- 
sider the  symptom  heat. 

Heat  alone  is  sufficient  to  account  for  certain  other  symptoms,. 
as  thirst,  diminished  secretion,  constipation,  loss  of  appetite,  etc. 
Heat  is  one  of  the  most  prominent  symptoms  of  the  inflammatory 
process,  and  it  was  formerly  believed  that  this  must  be  controlled  in 
order  to  cure  the  patient;  but  it  may  be  possible  that  the  heat  is  in 
some  way  beneficial,  especially  in  inflammatory  diseases  character- 
ized by  the  invasion  of  bacteria,  for  it  is  a  recognized  fact  that  bac- 

healthy  adult  is  70;  this  in  inflammation  may  be  increased  to  85,  go,  lOO,  or 
even  120,  according  to  the  severity  of  the  disease. 

A  "hard"  pulse  resists  the  pressure  of  the  finger,  and  rolls  under  it  like 
a  tense  cord,  being  due  to  the  great  force  with  which  the  blood  is  forced 
into  the  arteries. 

A  "full"  pulse,  as  the  term  indicates,  has  reference  to  the  amount  of 
blood  in  the  vessel,  actually  increasing  its  size,  which  is  appreciated  by  the 
touch  and  the  vessel  is  recognized  as  being  larger  than  usual. 

A  "quick"  pulse  is  recognized  by  the  touch  as  being  abrupt,  the  beats 
occurring  with  great  suddenness,  or  the  pulse  may  be  hard  and  quick  at 
the  same  time. 


THE   INFLAMMATORY    PROCESS    IN    GENERAL.  I3 

te'ria  are  susceptible  to  changes  of  temperature,  and  that  extremes 
of  high  or  low  temperature  check  their  growth.  It  has  been  found 
that  certain  micro-organisms  which  are  capable  of  producing 
disease  when  introduced  into  the  body  thrive  at  the  normal  body 
temperature,  but  cease  to  flourish  when  the  bodily  heat  is  raised. 
From  this  point  of  view  the  symptom  heat  assists  the  white  cor- 
puscle in  the  struggle  for  life  against  invading  bacteria,  and  may 
be  beneficial. 

Swelling  tells  us  much  of  the  character  of  the  inflammatory 
process,  and  is  an  important  and  constant  factor  in  all  acute  forms; 
yet  it  is  not  an  essential  element,  for  there  are  chronic  forms  in 
which  there  is  shrinkage  of  the  parts,  rather  than  swelling.  A 
quickened  circulation  of  the  blood  in  inflammation  has  been  noted, 
but  this  may  not  necessarily  account  for  the  swelling  of  the  in- 
flamed part,  for  blood  and  lymph  may  flow  to  the  part  in  increased 
quantities;  but  if  the  flow  from  the  part  is  equal  to  the  flow  to  it, 
there  is  no  accumulation  of  what  is  termed  inflammatory  exuda- 
tion, and  therefore  no  swelling,  while  if  there  is  an  obstruction  to 
the  exit  of  fluids  from  the  part,  there  is  swelling.  This  is  the 
result,  therefore,  of  the  accumulation  of  blood  and  lymph  in  the 
inflamed  area,  representing  material  which  has  escaped  from  the 
vessels  and  which  has  undergone  various  modifications. 

Cell-Migration. — The  main  feature  in  this  process  is  the 
escape  of  the  white  corpuscles,  or  what  is  known  as  the  "migra- 
tion of  the  leucocytes,"  first  observed  by  Cohnheim.  This  takes 
place  in  the  veins  and  capillaries,  there  being  no  evidence  that 
migration  of  blood-corpuscles  takes  place  from  the  arteries, 
although  these  vessels  may  become  distended  with  blood.  Ob- 
servation of  the  inflammatory  process  shows  a  rapid  blood-current 
which  is  followed  by  exudation  and  obstruction.  At  first  the 
blood-stream  shows  no  change  in  the  relation  of  the  red  and  the 
white  corpuscles  to  each  other,  but  later  the  movement  of  the  white 
corpuscles  is  retarded,  and  they  glide  more  slowly  along  the  sides 
of  the  vessel  wall  and  eventually  become  attached,  perhaps,  for  a 
short  time,  when  they  are  again  carried  along  by  the  current,  to 
become  at  last,  however,  attached  to  the  wall,  the  tendency  of  the 
white  corpuscles  to  stick  to  the  vessel  walls  becoming  more  and 
more  pronounced  until  the  leucocyte  fastens  itself  to  the  side  of  the 
vessel  and  stays  there,  thence  gradually  working  its  way  through 
to  the  outside.     The  corpuscle  seems  to  squeeze  itself  through. 


14 


THE    PRACTICE    OF    DENTAL   MEDICINE. 


becoming  much  changed  in  shape  in  the  process.  After  a  time  the 
red  blood-cells  follow  suit  and  are  seen  outside  the  vessel  walls, 
together  with  a  quantity  of  serum  which  has  escaped  also.* 

The  inflammatory  exudation  once  outside  the  bloodvessels  ex- 
tends in  dififerent  directions,  forming  masses  near  the  vessel  which 
grow  less  numerous  as  the  exudation  recedes  from  it.  It  is  not 
supposed  that  these  corpuscles  extend  haphazard  into  the  tissues, 
but  that  they  follow  certain  definite  channels,  lymph-  or  blood- 
channels,  and  it  has  been  observed  that  during  inflammation  there 
is  an  increased  flow  of  lymph  through  the  larger  as  well  as  the 
smaller  lymph-vessels. 

Fig.  I. 


That  the  white  blood-cells  actually  go  through  the  vessel  walls 
is  shown  by  introducing  a  coloring  material  into  the  blood,  stain- 
ing the  white  corpuscles  seen  first  inside  the  vessel  and  afterward 
outside.  Note  the  structure  of  the  vessel  wall.  (Fig.  i.)  The 
wall  is  silvered  so  that  the  outlines  of  the  endothelial  cells  which 
compose  it  may  be  seen.  The  joints  or  margins  of  these  cells 
may  be  supposed  to  allow  the  blood-cells  to  pass  through  them  at 
times,  but  there  is  no  direct  evidence  to  show  that  stomata  exist 
in  the  vessel  walls.  By  injecting  a  colored  fluid  under  sufficient 
pressure,  a  quantity  of  pigment  has  been  found  outside  the  vessel, 
favoring  the  supposition  that  this  pigment  escaped  through 
stomata  or  apertures  existing  in  the  walls  of  the  bloodvessels;  but 
there  exists  the  possibility  of  the  pressure  being  sufficient  to  rup- 

*  The  red  cells  have  no  inherent  power  of  passing  through  the  vessel 
walls,  but  it  has  been  suggested  that  it  is  possible  that  they  may  pass  by 
pressure  through  the  enlarged  stomata  made  by  the  passage  of  the  white 
cells. 


THE    INFLAMMATORY    PROCESS    IN    GENERAL.  1 5 

ture  the  vessel  walls  and  that  the  pigment  escaped  through  the  rent 
thus  made.  There  may,  however,  exist  minute  pores,  bej^ond  the 
power  of  the  microscope  at  present  to  reveal,  yet  large  enough  to 
permit  the  escape  of  the  white  blood-corpuscles  by  the  process  of 
squeezing  through,  in  which  their  shape  is  changed  and  their 
diameter  diminished  to  one-half  or  more.  It  is  probable,  also,  that 
the  inflammatory  process  renders  the  vessel  wall  more  permeable. 
However  this  may  be,  the  fact  that  blood-corpuscles  pass  through 
the  walls  of  the  vessels  is  easily  demonstrated,  as  shown  by  the 
following  experiments  made  by  the  writer  in  1884. 

The  method  found  to  be  most  convenient  for  this  purpose  was 
that  in  which  the  frog's  mesentery  is  used;  its  fineness  being  a 
quality  which  fits  it  admirably  for  microscopic  examination.  The 
frog  was  curarized,  and  laid  on  its  back  on  a  large  object-stage. 
An  incision  along  the  left  side  opened  the  abdomen,  and  a  loop 
of  intestine  was  drawn  out,  great  care  being  taken  not  to  unduly 
injure  the  parts  or  induce  hemorrhage.  The  mesentery  was  then 
drawn  gently  over  a  thin,  circular  cover-glass,  enclosed  by  a  ring 
of  cork,  and  fastened  to  the  stage  with  Canada  balsam  or  wax. 
The  mere  exposure  of  the  mesentery  to  the  air  has  been  found  suffi- 
cient to  start  inflammatory  action.  "Indifferent  solution"*  was 
used  to  prevent  the  exposed  parts  from  drying. 

At  first  a  general  dilatation  of  the  vessels  was  noticed,  begin- 
ning with  the  arteries  and  extending  to  the  capillaries  and  veins, 
and  while  the  flow^  of  blood  through  these  vessels  was  at  first  more 
rapid  (Fig.  2)  it  was  retarded  later  on  until  it  became  slower  than 
normal,  and  the  blood-cells,  which  formerly  could  not  be  distin- 
guished individually,  were  then  easily  recognized.  (Fig.  3.)  The 
blood  now  began  to  accumulate  in  the  capillaries  and  veins.  At  a 
later  period  the  white  blood-cells  were  seen  throwing  out  processes 
which  passed  into  the  wall  of  the  vessel,  and  eventually  through  it. 
This  escape  or  migration  of  the  white  cells  is  termed  diapedesis, 
and  by  this  process  in  six  or  eight  hours  the  veins  and  capillaries 
were  surrounded  by  these  leucocytes,  which  gradually  found  their 
way  into  the  surrounding  tissue.  (Fig.  4;  see  also  Fig.  5.)  It 
was  noticed  that  if  the  mesentery  became  strained  so  that  the  cir- 
culation was  interrupted,  migration  ceased  at  that  point. 

Bouchard  thinks  that  the  endothelial  cells  in  the  vessel  may 

*  "Indifferent  fluid"  or  "normal  salt  solution"  is  composed  of  one  tea- 
spoonful  (scant)  of  sodium  chlorid  to  one  pint  of  water. 


i6 


THE    PRACTICE    OF    DENTAL   MEDICINE. 


contract  and  assume  a  round  form,  leaving  large  openings  between 

them  through  which  the  corpuscles  pass;  also,  that  the  migration 

of  the  leucocytes  is  due  to  active  ameboid  movements  on  their 

part,  possibly  assisted  by  a  more  porous  condition  of  the  walls  of 

the  vessels. 

Fig.  2. 


a.  Vein.  bb.  Capillaries.  The  vessels  are  slightly  dilated,  and  the  blood-current  accelerated 
so  that  it  is  impossible  to  distinguish  the  individual  corpuscles,  except  in  the  smallest  (.u^j- 
illaries.    In  the  vein  is  seen  a  swiftly  passing  yellowish  stream. 


Fig.  3. 


a.  Vein.    bb.  Capillaries.    Retardation  of  current,  and  crowding  of  the  cells. 

The  fact  that  the  white  and  red  cells  will  escape  into  a  tissue 
whose  cells  are  dead  seems  to  contradict  the  theory  which  supposes 
that  increased  activity  of  neighboring  cells  will  cause  exudation. 


THE    INFLAMMATORY    PROCESS    IN    GENERAL, 


17 


Moreover,  recent  research  seems  to  warrant  the  supposition  that 

certain  products  of  bacteria,  when  located  near  the  bloodvessels, 

'have  the  power  of  attracting  white  blood-cells.     It  was  first  shown 

Fig.  4. 


a.  Vein.  b.  Artery.  The  migration  and  the  peripheral  distribution  of  the  white  blood-cells 
are  shown  by  the  round  black  figures.  (The  specimen  as  here  represented  had  been  under 
oti,<,vation  eight  hours.) 

Fig.  s. 


a.  Vein.  6  d.  Capillaries,  cc.  Complete  stagnation,  rf.  Escaped  white  blood-cells.  At  this- 
stage  the  preparation  had  been  under  observation  about  four  hours.  Stasis  here  obser\-ed  i& 
due  to  the  application  of  tincture  of  capsicum. 

by  Engelmann  that  chemical  substances  had  the  power  of  attract- 
ing or  repelling  cells  capable  of  independent  motion  (chemotaxis). 
Later,  this  process  was  observed  in  the  movements  of  the  leuco- 

3 


l8  THE    PRACTICE    OF    DENTAL   MEDICINE. 

cytes  by  Gabrischweigky,     Capillary  tubes  partly  filled  with  cer- 
tain substances  and  placed  in  the  tissues  of  animals  became  filled 
with  leucocytes ;  when  these  tubes  were  filled  with  indifferent  sub-  ■ 
stances,  only  a  small  number  of  leucocytes  entered  them;  other 
substances  exerted  a  repellent  action. 

Purpose  of  Cell-Migration. — These  observations  indicate  the 
beneficent  purpose  of  the  leucocytes  in  inflamed  tissue.  Any  dead 
material  in  the  body  quickly  becomes  filled  with  leucocytes.  In 
this  dead  material,  chemical  substances  are  formed  which  attract 
the  leucocytes.  At  points  of  inflammation  around  masses  of 
staphylococci  they  are  attracted  not  only  by  the  necrotic  tissue,  but 
by  the  bacteria  themselves.  Metchnikoff  has  shown  that  the  leu- 
cocytes have  the  power  (phagocytosis)  of  taking  up  and  destroying 
bacteria,  and  their  presence  therefore  must  afford  protection  to  the 
organism.  This  fluid  exudation  may  also  afford  a  useful  purpose 
in  diluting  poisonous  substances,  and  in  washing  them  away. 

As  further  proof  of  the  attractive  power  of  chemical  substances, 
necrotic  tissue,  and  bacteria,  it  has  been  shown  that  finely  pow- 
dered glass  may  be  introduced  into  the  tissue  causing  a  new 
formation  of  tissue,  an  infiltration  of  granulation  cells,  etc.,  without 
the  migration  of  any  leucocytes. 

If  we  now  return  to  the  migrating  cell  we  shall  find  that  it 
becomes  modified  in  its  passage  from  the  vessel  to  and  through 
the  tissues.  Both  blood-cell  and  serum  are  changed;  this  is 
effected  by  the  absorption  of  outside  material  into  the  cell  as  well 
as  by  a  giving  up  or  elimination  of  portions  of  the  cell  contents. 
These  and  probably  other  changes  so  completely  modify  the  blood- 
cells  and  serum  that  they  would  not  be  recognized  after  their 
escape  from  the  vessels  into  the  surrounding  tissue. 

"Pus." — We  have  spoken  of  the  fluid  which  passes  through  the 
vessels,  as  plasma,  red  and  white  corpuscles,  etc.  We  have  also 
said  that  in  the  passage  of  these  constituents  from  the  vessels  to  the 
surrounding  tissue  they  become  modified,  or  changed  so  as  not  to 
be  recognized;  they  are  therefore  entitled  to  a  new  name.  The 
term  "pus,"  however,  includes  more  than  this;  it  includes  what  are 
known  as  the  white  blood-corpuscles,  the  lymph-corpuscles,  the 
wandering  cells,  and  the  mucous  corpuscles,  all  of  which  have 
migrating  powers. 

The  observation  has  been  made  that  the  lymph-corpuscle  pos- 
sesses the  same  characteristics  as  those  found  in  the  white  blood- 


THE   INFLAMMATORY    PROCESS    IN    GENERAL.  19 

corpuscle.  The  lymph-corpuscles  are  seen  to  contain  one  or  more 
nuclei,  which  are  relatively  large  compared  with  the  amount  of 
protoplasm  surrounding  them.  These  same  characteristics  have 
been  noticed  in  the  cells  of  the  blood.  Both  in  blood  and  in  pus, 
cells  are  observed  to  contain  one  or  more  nuclei.  In  view  of  these 
observations,  therefore,  the  term  lymph-corpuscles  has  been  ap- 
plied simply  on  account  of  their  location;  for  instance,  in  the 
lymph-glands  they  are  known  as  lymph-corpuscles,  in  the  blood- 
vessels as  white  blood-corpuscles,  and  in  the  tissue  surrounding 
these  vessels  as  pus-corpuscles. 

Still  further,  there  is  reason  to  believe  that  the  migrated  white 
blood-corpuscle  divides  and  subdivides  in  the  inflammatory  pro- 
cess; indeed,  there  seems  to  be  no  otTier  way  of  accounting  for  the 
great  number  of  these  corpuscles  present  in  inflammatory  exuda- 
tion. 

These  inflammatory  products  continue  to  form  as  long  as  the 
inflammation  is  continued,  but  when  it  does  end  it  is  in  one  of 
three  ways, — in  resolution,  in  production,  or  in  destruction;  and 
when  the  cause  or  causes  are  removed  and  restoration  to  health 
has  begun,  we  assume  as  an  essential  fact  that  the  formation  of 
these  products  has  ceased. 

And  now  we  are  concerned  in  their  removal.  How  is  it  to  be 
accomplished?  We  may  have  the  inflammatory  exudation  in  all 
stages  of  fluidity,  and  under  some  circumstances  nearly  solid,  in 
which  case  the  cells  die  and  are  removed  by  "fatty  degeneration." 
As  the  cells  are  removed  by  this  process,  space  is  thus  afforded  for 
the  outflow  of  the  lymph-current,  and  a  considerable  amount  of  the 
inflammatory  product  is  carried  away  through  the  agency  of  the 
lymphatics.  These  products  are  still  further  reduced  by  the  return 
of  the  living  cells  to  the  lymph-  and  bloodvessels.  Thus  the 
various  materials  return  to  the  channels  from  which  they  came, 
and  the  normal  functions  are  again  established. 


20  THE    PRACTICE    OF    DENTAL    MEDICINE. 


DIVERSE  CONDITIONS  PRESENTING  TO  THE  DENTAL 
PRACTITIONER. 


CHAPTER    III. 

SYNCOPE. 

Synonym. — Fainting. 

Definition. — This  is  a  symptom  of  a  condition  in  which  the  heart 
fails  to  send  the  blood  to  the  extremities,  and  especially  to  the 
brain. 

Etiology. — Syncope  may  be  caused  by  a  great  variety  of  cir- 
cumstances and  conditions,  among  which  are  a  close  and  over- 
heated room;  the  sight  of  blood  or  of  some  operation;  various 
drugs,  as  cocain;  some  slight  operation  affecting  the  peripheral  dis- 
tribution of  the  fifth  nerve,  as  the  treatment  of  a  root-canal,  squeez- 
ing a  pimple,  etc.     Fear  very  often  causes  faintness. 

Treatment. — While  the  treatment  should  be  varied  to  suit  the 
dififerent  circumstances  in  each  case,  the  following  is  given  as  a 
brief  outline:  First  lower  the  head;  admit  fresh  air,  or  use  a  fan; 
loosen  the  clothing;  see  that  the  tongue  does  not  fall  back  in  the 
throat  and  obstruct  breathing;  apply  water  to  the  face,  and  put  a 
few  drops  of  aqua  ammonige  on  a  napkin  and  hold  it  cautiously  to 
the  nose.  If  the  patient  can  swallow,  administer  thirty  drops  of 
aromatic  spirits  of  ammonia  in  a  little  water,  or  fifteen  drops  of 
tincture  of  capsicum  in  water.  During  the  treatment,  if  the  patient 
does  not  recover  immediately,  assistants  may  be  employed  in 
chafing  the  hands  and  in  applying  warmth  to  the  feet. 

It  should  be  remembered  that  slowly  sipping  from  a  glass  of 
water  will  have  a  more  stimulating  effect  upon  the  heart  than  a 
small  dose  of  brandy  quickly  swallowed.  The  act  of  swallowing 
seems  to  remove  the  inhibitory  influence  over  the  heart,  allowing 
it  to  pulsate  more  freely. 

If  the  above  means  fail,  aromatic  spirits  of  ammonia,  or  brandy, 
may  be  injected  subcutaneously,  and  artificial  respiration  prac- 
ticed. 


HYSTERIA.  21 

CHAPTER    IV. 

HYSTERIA.* 

Synonym. — Hysterics. 

Definition.— Hysteria  is  described  as  a  functional  disturbance 
of  the  cerebro-spinal  axis,  characterized  either  by  special  mental 
symptoms  or  by  sensory,  motor,  vasomotor,  or  visceral  disorders, 
dependent  upon  a  variety  of  abnormal  physical  conditions. 

Etiology.  Remote  Causes. — All  agree  that  heredity  is  an 
important  factor  in  the  development  of  this  disease.  Briquet  has 
shown  that  from  hysterical  women  the  disease  has  been  transmitted 
to  more  than  half  the  daughters  in  the  two  following  generations. 
It  is  undoubtedly  true  that  hysteria  is  often  connected  more  or  less 
intimately  with  certain  other  morbid  states  of  the  system,  but  there 
is  little  evidence  to  show  that  it  is  dependent  upon  any  particular 
disease.  It  is  frequently  noticed  in  connection  with  a  tuberculous 
diathesis.  Grasset  has  recently  contributed  an  article  in  which  he 
expresses  his  belief  that  there  is  a  direct  connection  existing 
between  the  tuberculous  diathesis  and  hysteria.  :By  this  he  does 
not  mean  that  all  hysterical  subjects  have  tubercles  in  the  lungs, 
but  that  in  various  generations  suffering  from  such  a  diathesis,  one 
manifestation  of  it  is  often  found  in  hysteria. 

He  gives  several  interesting  cases  to  substantiate  this  theory, 
but  it  would  be  easy  to  prove  also  by  statistics  that  so  common  a 
disease  as  tuberculosis  was  related  to  many  other  complaints. 

It  is  generally  conceded  that  a  certain  mental  constitution  pre- 
disposes to  hysteria.  This  condition  is  described  as  a  state  in 
which  volition  is  not  well  balanced;  the  patient  is  changeable, 
capricious,  passing  rapidly  from  joy  to  sadness,  from  laughter  to 
tears. 

Hysteria  is  liable  to  occur  at  any  age,  but  it  is  well  understood 
that  it  occurs  with  greater  frequency  at  certain  periods  of  life. 
Statistics  show  that  hysteria  occurs  more  frequently  between  the 
ages  of  fifteen  and  thirty  than  at  any  other  time. 

*  In  view  of  the  fact  that  hysterical  patients  have  not  infrequently  com- 
plained of  being  the  victims  of  criminal  assaults,  it  would  be  a  wise  precau- 
tion to  have  a  witness  in  the  room  during  operations  for  patients  with 
known  hysterical  tendencies. 


22  THE    PRACTICE    OF    DENTAL   MEDICINE. 

Certain  occupatwns  predispose  to  hysteria,  especially  those 
which  necessitate  physical  fatigue  and  undue  mental  exertion. 
Men  often  suffer  from  hysteria  as  the  result  of  overwork  conjoined 
with  financial  embarrassment.  It  is  met  with  not  infrequently 
among  teachers,  particularly  those  who  are  engaged  in  the  ex- 
hausting labor  of  preparing  children  for  examinations.  The  inju- 
rious effect  of  overwork  in  the  American  school  or  college  in  the 
production  of  hysteria  is  undoubted,  acting  both  as  a  predisposing 
and  exciting  cause  of  this  disorder. 

One  of  the  essential  characteristics  of  hysteria  is  an  inordinate 
craving  for  sympathy,  which  may  or  may  not  be  under  the  patient's 
control.  This  sympathy  may  become  in  time  a  direct  cause;  for 
example,  there  once  came  under  the  writer's  observation  an  attack 
of  hysteria  in  a  young  woman  who  was  attended  by  a  sympathizing 
companion.  No  sooner  were  the  symptoms  abated  than  the  sec- 
ond young  woman  was  attacked  by  the  same  trouble.  The  first, 
as  soon  as  her  companion  revived,  was  again  hysterical,  and  so 
the  two  cases  continued,  alternating  several  times  before  the  com- 
plete recovery  of  either  took  place. 

Immediate  Dental  Causes. — Nervous  shock,  produced  in 
various  ways,  may  be  a  direct  cause  of  hysteria;  for  example,  it  may 
occur  as  the  result  of  prolonged  and  severe  dental  operations,  also 
of  ordinary  dental  operations  upon  a  susceptible  patient  during  the 
menstrual  period.  It  occurs  frequently  after  the  administration  of 
an  anesthetic  to  extract  a  tooth,  or  after  other  dental  operations. 
These  nervous  shocks  are  more  likely  to  produce  hysteria  in  those 
who  have  been  subjected  to  mental  strain  and  overwork;  in  such 
persons,  not  only  may  hysteria  be  produced  by  the  operations  and 
conditions  above  mentioned,  but  even  by  the  witnessing  of  an 
operation  upon  another. 

Pathology. — The  pathology  of  hysteria  has  not  at  the  present 
time  shown  us  any  radical  anatomical  changes.  When  these  have 
occurred  they  have  always  been  found  to  be  connected  with  some 
of  the  various  complications  which  may  attend  hysteria.  The 
ancients  thought  that  the  uterus  was  chiefly  concerned  in  hysteria, 
as  its  name  indicates.  As  late  as  1876  it  was  stated  by  Woodbury* 
that  cases  might  be  termed  hysterical  only  when  the  pathological 
sources  of  the  symptoms  were  found  in  the  uterus  or  ovaries;  and 
when  the  uterus  and  organs  associated  in  function  are  not  in  a 

*  See  Medical  and  Surgical  Reporter,  December  2,  1876. 


HYSTERIA.  23 

morbid  condition  no  symptoms  can  correctly  be  called  hysteria. 
But  Dr.  Chas.  K.  Mills*  states  the  case  better,  in  these  words:  "As 
the  uterus  and  ovaries  are  the  most  important  female  organs,  they 
are  therefore  a  frequent  source  of  reflex  irritation  in  hysterical 
patients." 

Later  observations,  however,  go  to  show  that  hysterical  symp- 
toms are  nearly  as  frequently  manifested  in  men  as  in  women. 
For  instance,  both  men  and  women  composed  the  religious  sect 
known  in  1760,  as  the  Jumpers.  In  their  religious  frenzy  they 
would  jump  for  hours  at  a  time.  The  Jumping  Frenchmen  of 
northern  Maine  furnish  a  striking  example  of  this  affection  occur- 
ring in  men.  Frenchmen  who  were  not  jumpers  have  worked  in 
the  same  camp  with  those  affected,  for  months,  without  being 
influenced,  when  suddenly  they  also  have  become  victims,  in  the 
following  manner:  One  of  the  jumpers  in  a  position  from  behind 
calls  out  "boo,"  when  those  who  are  affected  by  this  as  suddenly 
echo  "boo,"  jump  to  their  feet,  and  continue  to  leap  about  for 
many  hours,  during  which  time  they  are  joined  by  others.  Ever 
after  this,  those  who  have  been  thus  influenced  feel  impelled  to 
obey  the  slightest  command,  and  to  imitate  their  fellows  or  join 
them  in  their  frenzy  of  jumping  about.  A  similar  affection  was 
known  among  the  Siberians  in  which  both  men  and  women  were 
affected.  The  condition  was  known  to  the  Russians  as  "mirya- 
chit."  The  obedience  of  hypnotized  subjects  has  much  similarity 
with  the  affection  just  described,  and  may  well  claim  attention  as 
having  a  somewhat  close  relationship.  In  these  instances,  some 
kind  of  suggestion  was  necessary,  which  after  it  was  made  was 
carried  out  independently  of  the  will. 

Dr.  Mills  concisely  states  the  pathological  situation  as  follows: 

1st.  The  anatomical  changes  in  hysteria  are  temporary. 

2d.  These  changes  may  be  at  any  level  of  the  cerebro-spinal 
axis,  but  are  most  commonly  and  most  extensively  cerebral. 

3rd.  They  are  both  dynamic  and  vascular.  The  dynamic  are 
of  some  undemonstrable  molecular  character;  the  vascular  are 
either  spastic  or  paretic,  most  frequentl}'  the  former. 

4th.  The  psychical  element  enters,  in  that  either,  on  the  one 
hand,  violent  mental  stimuli  which  originate  in  the  cerebral  hemi- 
spheres are  transmitted  to  vasomotor  conductors,  or,  on  the  other 

*  Peppers  "System  of  Medicine,"  vol.  v.  p.  210. 


24  THE    PRACTICE    OF    DENTAL    MEDICINE. 

hand,  psychical  passivity  or  torpor  permits  the  undue  activity  of 
the  lower  nervous  levels. 

Symptoms. — ^Dr.  Mills  has  described  four  classes  of  hysterical 
cases,  which  not  only  help  in  using  the  symptoms  for  diagnosis, 
but  give  at  a  glance  an  admirable  and  comprehensive  view  of  the 
disease  in  its  different  phases.     His  classification  is  as  follows: 

1st.  Cases  in  which  the  symptoms  are  involuntary. 

2d.  Cases  in  which  the  symptoms  are  induced  and  become  in- 
voluntary. 

3rd.  Cases  in  which  the  symptoms  are  acted  or  simulated,  but 
in  which  the  patient,  because  of  impaired  mental  power,  is  irre- 
sistibly impelled  to  their  performance. 

4th.  Cases  in  which  the  symptoms  are  purely  acts  of  deception 
which  are  under  the  control  of  the  patient. 

In  the  first  class  it  may  seem  difhcult  to  see  how  the  psychical 
element  comes  in  if  the  symptoms  are  purely  involuntary,  but  it 
should  be  remembered  that  in  the  beginning  the  hysterical  symp- 
toms or  expressions  may  have  been  induced  by  psychical  influ- 
ence; these  being  repeated,  form  a  habit  which  is  so  strong  that  all 
expressions  of  hysterical  condition  are  entirely  beyond  the  patient's 
control.  Often  the  hysterical  countenance  or  facial  expressions 
may  be  observed.  In  mild  cases  no  radical  symptoms  are  to  be 
observed,  only  a  mental  exhilaration  and  mobility.  Sometimes 
there  is  complaint  that  a  ball  is  rising  in  the  throat  (globus  hys- 
tericus). 

An  hysterical  attack  may  come  in  a  variety  of  ways,  suddenly 
or  insidiously,  with  or  without  warning.  A  typical  and  most  con- 
stant condition  of  an  hysterical  attack  is  shown  in  alternate  laugh- 
ing and  crying,  often  in  wild  and  delirious  laughter  followed 
suddenly  by  violent  convulsive  sobbing  and  weeping.  By  "con- 
vulsive" in  this  condition  is  not  meant  a  rigid,  tonic  spasm,  but  a 
wild  throwing  about  of  the  arms  and  legs,  jerky  movements  of  the 
body,  often  accompanied  by  shouting,  screaming,  laughing,  etc., 
or  there  may  be  utter  silence  during  these  convulsive  movements, 
or  again,  a  low  mumbling  which  cannot  be  understood. 

As  illustrating  prominent  characteristics  of  hysteria,  and  at  the 
same  time  exhibiting  symptoms  of  this  disease,  the  following  may 
be  helpful:  In  the  Charite  Hospital  in  Berlin,  in  1801,  a  patient 
fell  into  strong  convulsions;  immediately  afterward  six  other 
patients  were  affected  in  the  same  way,  and  finally  eight  more  were 


HYSTERIA.  25 

attacked.  Mitchell  remarks,  "The  hysterical  state,  however  pro- 
duced, is  a  fruitful  source  of  mimicry  of  disease  in  its  every  form, 
from  the  mildest  of  pains  up  to  the  most  complete  and  carefully 
devised  frauds.  Its  sensitiveness  and  mobility,  its  timidity  and 
emotionalness,  its  greed  of  attention,  of  sympathy,  and  of  power  in 
all  shapes,  supply  both  motive  and  help,  so  that  while  we  must  be 
careful  not  to  see  mimicry  in  every  hysteric  symptom,  we  must,  in 
people  of  this  temperament,  be  unusually  watchful  for  this  form  of 
trouble,  and  at  least  reasonably  suspicious  of  every  peculiar  or 
unusual  phenomenon." 

One  of  the  most  mysterious  symptoms  or  conditions  connected 
.  with  hysteria  is  what  is  called  a  "phantom  tumor."  These  tumors 
may  occur  in  different  parts  of  the  abdominal  wall,  and  vary  in 
size  and  character.  They  are  diagnosed  by  administering  an  anes- 
thetic, when  the  tumor  disappears.  Among  the  many  other  hys- 
terical manifestations  are  anesthesia  (usually  local),  deafness,  blind- 
ness, perversions  of  the  senses  of  smell  and  taste,  hyperesthesia, 
painful  diseases  of  the  joints,  etc. 

Course,  Duration,  etc. — The  duration  and  general  course  of  this 
disease  are  as  uncertain  as  the  symptoms  and  pathology,  especially 
in  reference  to  the  acute  attacks,  but  the  underlying  predisposing 
condition  is  essentially  chronic. 

As  a  general  rule,  in  uncomplicated  cases,  the  disease  tends  to 
abatement  with  advancing  age,  and  its  presence  apparently  does 
not  tend  to  shorten  life  in  any  appreciable  degree. 

Prognosis. — The  prognosis  is  uncertain,  as  to  complete  and  per- 
manent recovery,  depending  much  upon  the  cause.  If  the  hys- 
terical condition  is  inherent  in  the  individual,  and  has  been  of  long 
standing,  the  prognosis  is  bad;  on  the  other  hand,  if  it  be  recently 
developed  in  a  previously  healthy  person,  there  is  much  room  for 
hope. 

Diagnosis. — Generally,  hysteria  presents  no  great  difficulty  in 
diagnosis,  but  there  are  many  exceptional  cases  in  which  the  prac- 
titioner finds  himself  in  doubt.  Hysteria  simulates  many  dis- 
eases; for  instance,  epilepsy.  From  this  disease  it  may  be  sepa- 
rated by  remembering  that  in  epilepsy  we  have  the  suddenness  of 
attack,  dilated  pupils,  absolute  loss  of  consciousness,  and  asphyxia, 
with  biting  of  the  tongue,  etc. ;  yet  hysteria  sometimes  passes  over 
into  a  condition  bordering  on  epilepsy, — liystero-epilepsy. 

Hysteria  may  be  distinguished  from  laryngitis,  peritonitis,  etc., 


26  THE    PRACTICE    OF    DENTAL   MEDICINE. 

by  noting  the  temperature  of  the  bod}-  and  by  close  examinations. 
The  tenderness  over  the  parts  in  hysteria  depends  more  upon  the 
mental  condition  than  that  which  attends  inflammation.  Also,  in 
the  case  of  an  involvement  of  the  larynx,  an  inspection  of  this 
organ  with  the  laryngoscopic  mirror  will  show  the  absence  of  true 
inflammation. 

Phantom  tumors  are  diagnosed,  as  already  mentioned,  by  the 
use  of  an  anesthetic,  under  which  they  disappear;  also  by  the  aid  of 
palpation  and  percussion  the  nature  of  their  contents  may  be  ascer- 
tained. It  is  sometimes  extremely  difflcult  to  determine  whether 
hysterical  patients  are  shamming  or  not,  but  in  the  ordinary  cases 
in  which  the  hysterical  condition  is  purposely  assumed,  watchful- 
ness will  suffice. 

In  those  cases  arising  in  dental  practice  a  thorough  knowledge 
of  the  symptoms  will  be  of  service,  and  in  the  majority  of  cases  a 
correct  diagnosis  may  be  made. 

Treatment. — When  an  acute  attack  of  hysteria  occurs  at  the 
dental  office,  it  is  no  time  for  the  study  of  the  essential  morbid 
phenomena  or  for  any  prolonged  investigation  as  to  the  cause,  but 
the  case  is  one  of  emergency  and  the  symptoms  must  be  treated 
immediately.  Neither  is  it  necessary  or  advisable  in  a  dental  work 
of  this  sort  to  discuss  the  preventive  and  moral  treatment  to  be 
advocated,  or  to  enter  into  an  elaborate  investigation  into  the 
etiological  factors  in  the  case  with  a  view  of  removing  the  cause; 
the  treatment  of  this  affection  will  therefore  be  considered  only  in 
its  application  to  such  cases  as  are  likely  to  arise  in  dental  practice. 

Whatever  the  medicinal  treatment  may  be,  there  is  always  a 
moral  principle  involved  which  must  be  kept  steadily  in  mind  in 
the  treatment  of  an  hysterical  case.  Thus  we  have  found,  in  the 
discussion  of  causes,  that  an  hysterical  condition  is  brought  into 
prominence  and  nourished  by  sympathy  and  indulgence,  if  indeed 
it  is  not  dependent  upon  these  qualities  in  others;  therefore  it  is 
necessary  in  treatment  to  be  firm  yet  kind,  to  insist  upon  obedience, 
never  wavering  in  the  carrying  out  of  any  measures  which  may  be 
proposed  in  the  presence  of  the  patient.  Such  patients  are  very 
watchful  to  notice  any  weakness  on  the  part  of  the  doctor,  making 
it  all  the  more  important  for  him  to  preserve  strict  discipline  in 
himself  as  well  as  in  patients  under  his  care. 

There  are  various  phases  of  hysterical  manifestations,  and  the 
treatment  should  vary  accordingly.     A  condition  often  met  with 


NEURALGIA.  2/ 

is  one  in  wliich  a  spasmodic  element  enters;  it  often  comes  on  in 
the  form  of  an  apparent  syncope,  followed  by  the  spasmodic  con- 
dition. The  loss  of  consciousness  may  be  partial  or  complete, 
and  the  spasms  are  usually  tonic  in  character.  In  such  cases 
the  treatment  must  first  be  directed  to  the  apparent  syncope. 
It  so  happens  that  a  dash  of  cold  water  in  the  face  is  one  of  the 
most  effective  local  measures  for  this  fainting  condition  and  at  the 
same  time  it  has  the  most  salutary  effect  upon  the  hysterical  state; 
it  is  therefore  to  be  commended  in  'these  cases.  Meanwhile  the 
patient's  head  should  be  lowered  sufficiently  to  invite  a  flow  of 
blood  in  that  direction.  If  syncope  is  profound,  a  hypodermic  in- 
jection of  aromatic  spirits  of  ammonia  or  brandy  may  be  given. 
When  the  patient  has  sufficiently  revived  as  far  as  circulation  is 
concerned,  and  the  spasmodic  condition  continues,  then  the  admin- 
istration of  sodium  bromid  or  potassium  bromid  is  of  value.  For 
the  alternating  laughing  and  crying  condition,  in  addition  to  moral 
restraint  a  full  dose  of  sodium  bromid,  or  a  teaspoonful  of  the 
elixir  of  valerianate  of  ammonium,  may  be  administered  in  water. 
Alcoholic  stimulants  should  rarely,  if  ever,  be  used;  for  in  those 
cases  in  which  the  extremities  are  cold  and  the  circulation  is  weak, 
the  elixir  above  mentioned  will  usually  be  sufftciently  stimulating. 
Symptoms  are  thus  combated  as  they  arise,  and  further  curative 
treatment  with  the  idea  of  removing  the  cause  should  be  referred 
to  the  general  practitioner.  This  may  not  always  be  necessary,  as 
many  cases  of  hysteria  are  dependent  upon  some  temporary  excite- 
ment and  need  no  further  treatment. 


CHAPTER    V 

NEURALGIA. 


Definition. — Neuralgia  is  a  disease  of  the  nervous  system  which 
as  yet  has  not  been  wholly  accounted  for  by  any  peripheral  lesion, 
and  which  is  characterized  by  intermittent  pain  usually  described 
as  darting,  stabbing,  boring,  etc. 

Etiology  and  Pathology. — It  must  be  admitted  that  it  is  quite 
impossible  to  make  out  a  clear  statement  of  the  etiology  of  this 


28  THE    PRACTICE    OF    DENTAL   MEDICINE. 

subject  as  distinguished  from  its  pathology.  In  discussing  causes 
it  is  difficult  to  arrive  at  a  decision  as  to  what  is  cause  and  what  is 
effect.  Very  little  can  be  said  definitely  in  regard  to  the  pathology 
of  neuralgia.  There  are  those  who  believe  that  it  is  an  expression 
of  a  neurosis,  which  is  9,  functional  affection  of  the  nerve-centers. 
There  is  much  to  support  this  in  the  fact  that  many  persons  suffer 
from  neuralgia  without  apparent  outward  cause  or  irritation. 
Other  writers  believe  neuralgia  to  be  due  to  a  congesteid  condition 
of  the  nerves,  or  to  some  pressure;  that  of  a  tumor,  for  example. 
Reynolds  thinks  it  probable  that  in  all  cases  of  neuralgia  there  is 
either  atrophy  or  a  tendency  to  it,  in  the  sensory  root  of  the  painful 
nerve  or  in  the  central  gray  matter  with  which  it  comes  in  closest 
connection. 

That  a  neurotic  condition  is  hereditary  is  quite  well  established, 
as  it  has  been  observed  to  be  transmitted  to  successive  generations 
of  a  family.  There  has  also  been  noticed  in  the  same  family  a 
tendency  to  other  neuroses,  as  insanity,  paralysis,  hypochondriasis, 
etc.  Again,  it  may  be  said  that  neuralgia  may  coexist  with  any  of 
these  affections.  With  this  tendency  to  neuralgia  there  may  be 
transmitted,  also,  a  weakened  or  faulty  nervous  sytem.  In  support 
of  the  idea  of  heredity  just  expressed,  and  of  inherent  constitu- 
tional weakness,  especially  in  the  nervous  system,  we  may  recall 
many  cases  of  neuralgia  of  the  fifth  nerve  in  which  no  local  or  pe- 
ripheral cause  has  been  sufficient  to  explain  the  condition,  and  in 
which  we  must  assume  some  constitutional  peculiarity  or  weakness 
in  the  individual,  and  it  will  probably  be  found  upon  investigation 
that  these  exceptional  cases  belong  to  neurotic  families.  Reynolds 
says  that  excessive  drinking  tends  to  produce  degeneration  of  the 
nervous  centers  and  predisposes  to  neuralgia,  and  that  the  descend- 
ants of  drunkards,  who  usually  give  evidences  of  an  enfeebled 
nervous  organism,  are  decidedly  prone  to  this  disease. 

In  neuralgia  of  the  fifth  nerve,  variously  designated  as  proso- 
palgia, tic  douloureux,  epileptiform  neuralgia,  Fothergill's  disease, 
etc.,  the  underlying  causes  are  practically  the  same  as  those  which 
produce  the  disease  in  other  parts.  Certain  dyscrasise,  as  results 
of  lead-poisoning,  syphilis,  malaria,  etc.,  which  may  be  classed  as 
causes  predisposing  to  the  disease  in  general,  are  especially  con- 
nected with  neuralgia  of  the  fifth  nerve;  to  these  should  be  added 
certain  immediate  causes,  as  changes  in  the  structure  of  the  nerve, 
exostoses,  pericementitis,  irritation  of  the  dental  pulp  from  various 


NEURALGIA.  29 

sources,  hypercementosis,  dental  erosion,  impacted  teeth,  irregular 
eruption  of  the  wisdom  teeth,  etc.  In  fact,  nerve  irritation,  from 
whatever  source,  which  in  itself  is  not  sufficient  to  produce  neural- 
gic pain  may  vet  be  accountable  for  neuralgia  in  its  severest  form 
when  coupled  with  the  underlying  or  predisposing  cause. 

Symptoms. — We  may  expect  to  find  expressions  of  this  disease 
in  persons  in  whom  there  is  a  neurotic  diathesis,  and  in  those  who 
are  enfeebled  from  any  cause.  It  should  be  remembered  that  while 
a  patient  may  present  a  fairly  healthy  appearance  and  have  a  good 
amount  of  muscular  strength,  he  may  yet  be  in  a  debilitated  condi- 
tion. Upon  a  closer  examination  of  these  causes  it  will  be  found 
that  the  nervous  system  has  given  warning,  in  one  way  or  another, 
of  its  weakened  condition,  and  on  inquiry  into  the  history  of  the 
case  a  clear  story  of  hereditary  transmission  will  usually  be  ob- 
tained. 

The  pain  of  neuralgia  is  paroxysmal,  especially  so  at  first.  As 
it  goes  on,  the  intervals  between  the  paroxysms  of  pain  grow  less 
and  less,  and  the  regularity  with  which  they  come  on  is  interrupted. 
While  the  nature  of  the  pain  may  vary  under  different  conditions, 
it  is  usually  of  a  sharp  lancinating  character,  darting  like  an  electric 
shock  and  running  through  the  parts  affected  with  the  rapidity  of 
lightning.  It  may  vary  from  this  to  a  dull  ache,  or  to  a  pain  like 
that  produced  by  thrusting  needles  into  the  skin.  In  neuralgia 
of  the  fifth  nerve,  and  especially  that  designated  as  tic  douloureux, 
the  first  attacks  may  be  moderate  and  transient,  not  unlike  an  ordi- 
nary toothache,  and  may  even  be  located  in  some  particular  tooth, 
or  may  shift  from  one  tooth  to  another.  Neuralgia  in  the  past  has 
been  the  cause  of  the  loss  of  many  teeth;  one  after  another  has 
been  extracted  in  the  vain  hope  of  finding  the  painful  one.  It 
may  continue  for  weeks  or  even  months  before  the  pain  becomes 
strikingly  characteristic,  and  when  this  point  is  reached  there  is 
nothing  more  excruciating  than  the  torture  which  is  suffered. 
The  pain  comes  on  like  a  lightning-stroke,  and  the  muscles  of  the 
face  on  the  affected  side  are  convulsed,  the  eyes  suffused  with  tears, 
and  the  patient  groans  and  cries  out  as  one  in  the  extremity  of 
agony.  In  the  intervals  between  these  attacks,  while  there  may  be 
no  pain,  very  frequently  tender  spots  may  be  found  along  the 
course  of  the  superficial  nerves.  Another  characteristic  of  this 
condition  is  the  extreme  sensitiveness  of  the  patient  to  the  merest 
trifles,  such  as  a  slight  breath  of  air,  the  slamming  of  a  door,  or  any 


30  THE    PRACTICE    OF    DENTAL   MEDICINE. 

movement  on  his  own  part.  He  hardly  dares  to  breathe  in  his  sus- 
pense, expecting  the  onset  of  the  next  attack.  When  these  parox- 
ysms of  pain  are  brought  on  by  eating,  and  they  become  so  con- 
tinuous that  not  only  the  appetite  but  sleep  is  lost,  then  the  general 
health  suffers;  otherwise  there  may  be  no  serious  impairment  of  the 
health. 

Neuralgia  of  the  fifth  nerve  may  occur  in  one  or  all  of  its  three 
divisions;  more  frequently  it  is  confined  to  one.  If  the  ophthalmic 
division  of  this  nerve  is  affected,  the  pain  is  located  in  the  forehead 
and  temples,  darting  through  the  eye  and  in  the  eyelid,  the  most 
tender  spot  being  at  the  supraorbital  foramen.  If  the  second  divi- 
sion is  affected,  the  pain  is  felt  in  the  superior  maxilla,  in  the  upper 
teeth  and  the  upper  lip;  and  one  may  look  for  the  tender  point  at 
the  infraorbital  foramen.  If  the  inferior  maxillary  division  is 
affected  the  pain  is  felt  in  the  lower  jaw  and  in  the  teeth.  The 
tender  spot  in  this  case  may  be  looked  for  in  the  region  of  the 
mental  foramen. 

In  the  light  of  these  statements,  one  cannot  expect  to  surely 
locate  the  immediate  cause  of  neuralgic  pain,  even  if  it  exists  in 
some  particular  tooth;  but  none  the  less  surely  may  such  a  cause 
exist,  and  one  should  search  diligently  throughout  the  entire  den- 
tures if  the  pain  affects  either  of  them.  If  the  cause  is  not  then 
apparent  the  eyes  should  be  examined,  also  the  nose  and  the  post- 
nasal space. 

Diagnosis. — ^The  following  points  are  to  be  observed  in  the 
diagnosis:  Where  and  in  what  direction  is  the  pain?  Is  it  unilat- 
eral? Does  it  correspond  to  the  course  of  a  certain  nerve-branch 
or  branches?  Is  it  of  an  intermittent  character?  Are  tender  spots 
to  be  found  after  a  certain  stage  along  the  superficial  nerves? 
And,  lastly,  has  the  patient  or  any  of  his  family  previously  suffered 
from  neuralgia? 

Treatment. — The  treatment  of  neuralgia  should  have  one  or 
more  of  the  following  objects  in  view:  First,  the  removal  of  the 
local  or  immediate  cause;  second,  the  improvement  of  the  general 
condition ;  third,  the  immediate  relief  of  pain  by  the  use  of  narcotic 
stimulants,  and  those  remedies  which  have  a  direct  influence  upon 
the  affected  nerve.  In  enumerating  the  different  local  causes  aris- 
ing within  the  mouth  the  impression  should  be  conveyed,  not  that 
these  alone  are  responsible  for  the  condition  which  is  under  discus- 
sion, but  that  the  neuralgic  diathesis,  which  is  nearly  always  pres- 


NEURALGIA.  3I 

ent,  plus  an  irritated  pulp  or  dental  nerve,  are  together  sufficient  to 
cause  neuralgia.  In  the  absence  of  either  of  these  factors  there 
would  be  no  neuralgic  symptom.  This  point  needs  emphasis,  for 
the  reason  that  the  laity,  and  many  dental  practitioners  as  well,  are 
prone  to  designate  the  pain  arising  from  pulpitis  or  pericementitis, 
in  certain  stages,  as  that  of  neuralgia.  One  can  easily  see  the  drift 
of  popular  opinion  from  the  fact  that  when  a  patient  is  told  that 
the  pain  which  he  has  is  neuralgia,  he  is  immediately  recon- 
ciled to  it,  and  does  not  expect  the  dentist  to  do  anything  for  its 
radical  cure.  The  cause  having  been  found,  whether  it  be  an  irri- 
tation of  the  pulp  from  a  large  metal  filling,  pulp-stones,  irritation 
of  the  pericementum,  erosion,  impacted  teeth,  crowded  teeth,  ocu- 
lar troubles,  obstructed  ducts  or  outlets  in  the  mouth  or  nose, 
salivary  calculi,  or  other  foreign  bodies,  the  treatment  as  elsewhere 
indicated  for  these  conditions  should  be  instituted. 

In  the  consideration  of  constitutional  treatment,  the  diet  should 
receive  attention.  In  nearly  all  cases  nutrition  is  impaired,  and  in 
such  cases  it  is  impossible  to  overestimate  the  importance  of  sup- 
plying animal  fats  to  the  system.  It  is  probably  true  that  those 
persons  who  are  in  greatest  need  of  fats  have  a  dislike  "for  fatty 
foods  and  have  consequently  avoided  their  use.  J.  Russell  Rey- 
nolds, of  London,  says  that  several  times  in  his  practice  he  has 
seen  patients  entirely  lose  neuralgic  pain  of  long  standing  after  the 
adoption  of  a  simple  alteration  of  their  diet  by  which  the  proportion 
of  fatty  ingredients  in  it  was  considerably  increased.  Among  the 
fats,  cod-liver  oil  should  occupy  the  first  place.  But  this  may  dis- 
agree with  the  stomach,  and  in  that  case  as  much  butter  as  possible 
should  be  used  with  the  food,  and  cream  should  be  taken  in  such 
quantities  as  the  patient  can  bear.  In  cases  of  marked  anemia, 
iron  in  some  form  not  injurious  to  the  teeth  should  be  employed. 
As  arsenic  is  applicable  to  so  many  cases,  a  pill  containing  both 
iron  and  arsenic  may  be  recommended;  for  instance,  arsenate  of 
iron,  -J  of  a  grain  three  times  daily,  after  food. 

If  there  is  a  suspicion  that  malaria  may  be  connected  with  the 
case,  quinin  should  be  prescribed;  it  should  be  tried  in  all  cases 
in  which  the  pains  are  markedly  intermittent. 

Among  those  constitutional  remedies  which  have  for  their 
object  the  alteration  of  the  blood,  the  potassium  iodid  is  useful. 
Many  cases  of  neuralgia  arise  from  syphilis,  due  probably  to  a  local 
deposit  somewhere  along  the  course  of  the  afifected  nerve.     In  such 


32  THE    PRACTICE    OF    DENTAL    MEDICINE. 

a  case  the  potassium  iodid  should  be  administered  in  large  doses. 
If,  in  other  cases,  the  neuralgia  is  due  to  a  rheumatic  or  gouty 
diathesis,  the  patient  should  receive  antirheumatic  treatment. 

Of  the  narcotic  stimulant  remedies,  especially  in  neuralgia  of 
the  fifth  nerve  with  dental  origin,  hyoscyamus  is  to  be  commended; 
it  is  as  efficient  as  its  rival  remedy,  belladonna,  and  possesses  in 
addition  an  hypnotic  property.  In  cases  of  suspected  neuralgia,  or 
of  dental  irritation  with  neuralgic  symptoms,  gelsemium  is  mark- 
edly successful;  but  for  the  immediate  relief  of  pain  there  is  no 
remedy  that  can  be  compared  to  opium. "^^  One  of  the  best  ways  in 
which  to  use  it  is  in  a  combination  of  morphin  and  belladonna;  or 
what  is  better,  a  subcutaneous  injection  of  morphin  and  atropin; 
morphin  gr.  |,  and  atropin  gr.  y|^.  Aconite,  in  certain  cases  of 
neuralgia,  is  an  excellent  remedy.  The  many  preparations  of 
aconite  vary  greatly  in  strength,  but  one  of  the  safest  of  them  is 
that  recommended  in  the  Ph.  Germ.,  of  a  ten  per  cent,  tincture,  of 
which  the  maximum  single  dose  'for  an  adult  is  trjj  ix. 

Electricity  should  be  mentioned  among  remedies  for  neuralgia, 
but  it  is  uncertain  in  its  action  from  the  fact  that  it  is  so  little  under- 
stood. The  galvanic  current  has  been  used  along  the  course  of  the 
aflfected  nerves  with  astonishingly  good  results  in  cases  of  sciatic 
neuralgia,  but  there  is  a  lack  of  experience  in  its  application  to  the 
fifth  nerve. 

In  regard  to  the  general  treatment  and  hygiene,  sunshine  is 
very  beneficial.  The  patient  should  be  out  in  the  sun  as  much  as 
possible,  even  to  the  extent  of  lying  with  the  entire  body  exposed 
to  the  rays  of  the  sun  for  many  hours  in  the  day. 

Patients  who  are  sensitive  to  changes  of  the  weather  should  be 
particularly  careful  to  wear  proper  clothing,  and  should  strengthen 
and  equalize  the  cutaneous  circulation  by  friction  and  baths.  Sleep 
and  rest  are  essential.  Easily  digested  and  nourishing  food  is  of 
the  greatest  importance,  since  neuralgia  patients  often  have  insuffi- 
cient nutrition.  A  diet  of  eggs  and  milk  given  at  short  intervals 
during  the  day  will  be  found  beneficial.  Dr.  Weir  Mitchell's  regi- 
men has  much  in  it  that  may  be  adopted  with  advantage. 

Lastly,  a  change  to  a  warm,  dry  climate  will  often  effect  a  cure. 

*  Great  caution  should  be  used  to  avoid  inducing  the  opium  habit. 


ADMINISTRATION    OF    ANESTHETIC    AGENTS.  33 


CHAPTER    VI. 

CONSIDERATION  OF  SUBJECTS  INVOLVED  IN  THE  ADMIN- 
ISTRATION OF  ANESTHETIC  AGENTS. 

The  Patient. — It  is  true  that  in  many  cases  the  administering 
of  an  anesthetic  is  attended  with  little  or  no  risk,  yet  there  are  con- 
ditions demanding  a  careful  inquiry  both  into  the  nature  of  the 
anesthetic  and  the  physical  state  of  the  patient.  It  has  been  said 
that  the  use  of  chloroform  for  a  surgical  operation  upon  a  patient 
who  is  afifected  with  heart  disease  is  safer  than  without  the  use  of 
this  anesthetic;  that  the  shock  of  the  operation  would  prove  far 
more  serious  than  the  effect  of  the  anesthetic  agent.  This  may  or 
may  not  be  true;  much  depends  upon  the  mode  of  administration, 
which  may  be  modified  in  accordance  with  the  condition  of  the 
patient,  and  very  much  depends  upon  the  stage  of  the  disease, 
the  general  condition  of  the  individual,  and  the  existence  of  com- 
plications. 

There  must  also  be  taken  into  account  the  operation  itself; 
its  character,  short  or  prolonged,  minor  or  major;  the  probable 
loss  of  blood,  etc.;  therefore  no  rule  can  be  made  which 
shall  govern  all  cases.  A  hundred  conditions  as  to  administra- 
tion, the  anesthetic,  the  condition  of  the  patient,  and  the  opera- 
tion, may  come  into  the  question  whether  a  patient  with  heart 
disease  may  or  may  not  safely  take  an  anesthetic.  Therefore,  in 
naming  conditions  under  which  it  would  not  be  wise  to  administer 
an  anesthetic,  one  should  take  the  above  factors  into  considera- 
tion. 

It  will  be  found  in  practice,  that  there  are  few  cases  in  which 
some  anesthetic,  local  or  general,  is  not  admissible.  For  example, 
in  certain  cases  in  which  it  may  be  deemed  unsafe  to  administer 
ether,  chloroform,  or  nitrous  oxid,  whiskey  may  be  substituted 
with  good  effect. 

A  patient  may  shrink  from  the  simple  fact  that  he  is  to  be  ren- 
dered unconscious,  as  shown  by  the  frequent  remark,  "I  would 
rather  suffer  pain  than  lose  consciousness."  With  patients  in 
whom  ether,  or  other  general  anesthetic,  is  contra-indicated,  a 
resort  mav  be  had  to  some  safe  local  anesthetic,  as  a   i   to  200 


34  THE    PRACTICE    OF    DENTAL    MEDICINE. 

solution  of  carbolic  acid.  Others  have  declared  that  they  did  not 
fear  the  pain  especially,  but  that  they  did  not  wish  to  be  conscious 
when  the  operation  was  performed;  in  such  cases,  the  mere  extrac- 
tion of  a  tooth  with  the  fingers  has  been  known  to  cause  alarming 
pallor  of  the  face  and  palpitation  of  the  heart. 

In  cases  of  extreme  nervous  exhaustion  and  anemia  in  which 
severe  operations  about  the  mouth  cannot  be  delayed  and  when 
an  anesthetic  is  imperative,  the  greatest  care  is  necessary  in  order 
to  keep  up  the  heart's  action;  the  keenest  watchfulness  and  best 
judgment  must  be  used  in  order  to  avoid  shock  and  pain  on  the 
one  hand,  and  the  taking  of  too  much  anesthetic  on  the  other.  In 
advanced  cases  of  pulmonary  tuberculosis,  ether  should  generally 
be  prohibited,  yet  it  has  been  administered  in  cases  of  pronounced 
phthisis  with  safety.  It  is  contra-indicated  in  tumors  of  the  brain, 
or  when  the  brain  is  in  an  irritable,  congested  condition. 

Any  obstruction  to  the  breathing  is  proportionately  hazardous, 
as  this  condition  favors  asphyxia  by  interfering  with  the  proper 
ox3'genation  of  the  blood.  Such  obstructions  may  be  edema  of 
the  glottis,  enlarged  tonsils,  or  some  inflammatory  condition  of  the 
lung  or  its  lining  membrane.  In  Bright's  disease  of  the  kidneys, 
in  cases  in  which  there  has  been  degeneration  of  structure,  the 
administration  of  ether  is  attended  with  considerable  risk,  yet  it  has 
been  administered  many  times  safely  to  patients  having  pro- 
nounced kidney  disease. 

Ether  has  also  been  administered  to  patients  suffering  from 
what  is  called  heart  disease,  without  ill  effect;  for  instance,  in  valvu- 
lar lesions,  s-tenosis,  etc.,  but  there  is  one  condition  of  the  heart  in 
which  ether  should  not  be  given;  it  is  what  is  known  as  "fatty 
heart,"  or  fatty  degeneration  of  the  heart.  This  is  a  condition  of 
the  heart  in  which  the  organ  may  rupture,  or  death  set  in,  at  a 
time  when  no  organ  in  the  body  can  be  found  sufficiently  diseased 
to  be  held  accountable.  The  change  in  the  heart  structure  is  well 
recognized  after  death;  there  being  a  substitution  for  the  heart- 
muscle  fiber  of  fat  granules  and  oil,  but  there  is  no  infallible  sign 
during  life  by  which  we  can  know  that  this  change  is  taking  place; 
we  may,  however,  by  the  observation  of  certain  symptoms,  have 
our  suspicions  sufficiently  aroused  to  be  on  our  guard. 

The  heart  in  which  there  is  a  fatty  degeneration  going  on  is  a 
weak  one,  characterized  by  a  weak  circulation,  as  denoted  by  the 
pulse    and    by    feeble,    ill-defined    heart-sounds.     Sometimes    the 


ADMINISTRATION    OF    ANESTHETIC    AGENTS,  35 

pulse-rate  is  low,  and  sometimes  high,  but  rarely  changing  from 
one  to  the  other.  There  is  in  connection  with  the  above  symp- 
toms a  gradual  loss  of  flesh.  The  "arcus  seniHs,"  an  expression  of 
fatty  degeneration  in  the  eye,  has  been  held  to  be  diagnostic  of  fatty 
heart,  but  this  is  not  conclusive.  Further  symptoms  are  pain 
across  the  upper  part  of  the  sternum,  and  severe  pain  in  the  heart 
itself.  The  patient  occasionally  draws  a  long  breath,  and  suffers 
from  seizures  in  which  his  breath  seems  to  cease  for  a  time,  and  he 
becomes  unconscious. 

Dropsy  is  neither  a  constant  nor  a  diagnostic  symptom;  its 
presence  or  absence  does  not  indicate  anything,  nor  would  all  the 
above  symptoms  be  necessarily  found  in  fatty  heart.  Persons  who 
have  this  disease  are  often  afflicted  with  faintness,  and  a  sensation 
of  cold  in  the  extremities. 

With  the  structure  of  the  heart  thus  weakened  by  the  substi- 
tution of  fat,  it  is  not  surprising,  from  the  pressure  within  its  walls 
which  is  required  to  force  the  blood  into  the  general  circulation, 
that  these  walls  may  gradually  yield  and  dilatation  occur,  with  its 
complication  of  symptoms;  and  that,  occasionally,  the  organ  itself 
may  be  ruptured. 

Therefore,  it  is  always  best  that  the  operator  should  be  fully 
apprised  of  the  patient's  condition  by  a  thorough  examination, 
either  by  himself  or  a  competent  diagnostician ;  and  that  he  should 
govern  himself  accordingly,  either  by  withholding  the  anesthetic 
entirely,  or  by  using  the  precautions  which  the  condition  of  the 
patient  demands. 

The  Agent.- — -The  choice  of  the  anesthetic  should  be  based  upon 
the  patient's  condition  and  the  character  of  the  operation.  Prac- 
tically, at  the  present  tim^e  the  choice  will  lie  between  ether,  nitrous 
oxid,  and  chloroform;  while  in  other  cases  drugs,  as  morphin, 
atropin,  spiritus  frumenti,  etc.,  may  be  indicated;  and  in  still  other 
cases  rapid  breathing  or  hypnotism  may  be  required. 

In  nitrous  oxid  we  have  an  agent  which  is  comparatively  safe, 
not  unpleasant  in  its  action,  sufficiently  powerful,  but  of  short  dura- 
tion. It  is  in  daily  use,  and  its  record  has  now  become  established 
so  that  it  takes  favorable  rank  among  other  anesthetics. 

It  is  thought  that  many  former  accidents  occurred  on  account 
of  impure  gas,  as  it  was  manufactured  for  use  with  imperfect  appa- 
ratus and  kept  in  tanks  an  indefinite  time,  ^^'hatever  weight  is 
attached  to  this,  there  is  no  excuse  for  using  an  impure  article  now. 


36  THE    PRACTICE    OF    DENTAL    MEDICINE. 

and  he  who  does  not  make  sure  that  he  is  using  an  absolutely  pure 
article  is  deserving  of  the  severest  condemnation. 

Bartholow  describes  the  first  eflfects  of  this  gas  as  filling  the 
patient's  mind  with  illusions,  causing  him  to  break  out  into  sing- 
ing, declamation,  sobbing,  etc.,  and  often  to  show  a  fighting  ten- 
dency. He  adds  that  when  this  agent  is  used  to  produce  anes- 
thesia for  surgical  purposes  the  inhalation  is  forced,  the  counte- 
nance assumes  a  frightful  aspect,  the  face  becomes  pale,  there  is 
stertorous  breathing,  the  eyes  protrude,  and  the  face  changes  to  a 
bluish  and  purplish  tint.  This  description  should  be  modified  in 
the  light  of  modern  experience.  Small  quantities  of  nitrous  oxid, 
administered  for  the  purpose  of  obtunding  sensitive  dentin,  with 
or  without  the  admission  of  air,  rarely  produce  the  laughing  ele- 
ment or  a  fighting  tendency;  indeed  the  excitement  attending  the 
inhalation  of  nitrous  oxid  is  no  more  than  may  be  observed  in  a 
similar  use  of  ether  or  chloroform. 

Furthermore,  the  admixture  of  air,  or  oxygen  gas,  does  not 
appear  to  cause  excitement,  but,  on  the  other  hand  it  has  proved  to 
be  a  decided  advance  in  the  administration  of  this  agent,  inasmuch 
as  it  obviates  entirely  the  asphyxiating  symptoms. 

To  Dr.  Frederic  Hewitt  of  London  belongs  the  credit  of 
devising  and  publishing  a  method  by  which  a  definite  amount  of 
oxygen  gas  may  be  admitted  and  mixed  with  the  nitrous  oxid  at 
will.*  It  takes  a  little  longer  to  obtain  full  anesthesia,  but  the 
results  are  very  satisfactory.  While  some  operators  prefer  to 
admit  air  instead  of  oxygen.  Dr.  Hewitt  believes  that  oxygen  gas 
possesses  marked  advantages  over  air.  Some  eminent  writers  hold 
the  opinion  that  the  efifect  of  nitrous  oxid  gas  is  one  of  asphyxia, 
pure  and  simple,  but  while  symptoms  of  asphyxia  may  be  present 
under  the  full  efifect  of  NoO,  there  is  a  true  anesthetic  effect  also, 
as  shown  in  a  paper  published  in  the  Dental  Cosmos  for  Novem- 
ber 1895,  by  Dr.  J.  D.  Thomas  of  Philadelphia. 

Sulfuric  ether  is  probably  the  safest  and  at  the  same  time  the 
most  efficient  anesthetic  agent  known,  but  chloroform  is  used 
exclusively  in  many  European  hospitals  and  in  some  of  the  States 
of  this  country. 

The  relative  merits  of  ether  and  chloroform  have  been  well  eluci- 

*  See  Journal  of  the  British  Dental  Association  for  June  1894;  also  paper 
by  Dr.  E.  C.  Kirk,  Dental  Cosmos  for  December  1894. 


ADMINISTRATION    OF   ANESTHETIC   AGENTS,  37 

dated  in  an  article  by  W.  S,  Caldwell,  M.D.*  He  has  noticed  the 
gradual  increase  in  the  use  of  ether  over  chloroform  as  an  anes- 
thetic, especially  in  Great  :Britain  during  the  last  thirty  years.  Dr. 
Caldwell  says  that  when  he  is  reminded  of  the  safety  of  chloroform 
if  properly  administered,  he  recalls  with  a  shudder  the  deaths  that 
he  has  seen  occur  while  patients  were  being  operated  on  by  the 
great  lights  of  surgery  in  Paris,  Vienna,  and  Berlin;  while  he  has 
never  seen  a  patient  die  under  the  administration  of  ether.  He 
states  that  the  mortality  reports  showing  the  number  of  deaths  by 
chloi-oform  and  ether  are  compiled,  in  the  main,  from  the  statistics 
kept  by  large  hospitals  where  anesthetics  are  most  skillfully  given. 
He  concludes  that  as  chloroform  is  the  more  dangerous  agent,  its 
advocates  admitting  that  it  requires  more  skill  for  its  administra- 
tion; and  as  such  skill  is  not  possessed,  in  his  opinion,  by  one  in 
one  hundred,  that  anesthetic  should  be  used  which,  though  unskill-' 
fully  given,  is  not  likely  to  result  in  the  death  of  the  patient. 

Dr.  Caldwell  sent  out  in  August,  1896,  over  two  hundred  cir- 
cular letters  to  surgeons  of  the  United  States,  north  of  Baltimore 
and  St.  Louis,  asking  answers  to  the  following  questions : 

1.  Do  you  generally  use  ether  or  chloroform  in  your  practice  as  an 
anesthetic  agent? 

2.  State  briefly  your  reasons  for  preferring  the  one  or  the  other. 

3.  How  many  deaths  have  you  had  in  your  practice  from  chloroform? 
From  ether? 

4.  How  many  deaths  do  you  know  of  that  have  occurred  in  the  prac- 
tice of  other  surgeons  from  chloroform?     From  ether? 

The  results  of  these  questions,  as  he  remarks,  were  as  sectional 
as  politics.  Nearly  every  advocate  of  chloroform  was  west  of 
Buffalo.  Chicago  was  about  equally  divided  between  chloroform 
and  ether.  St.  Louis  was  largely  for  chloroform,  while  New  York, 
Philadelphia  and  Boston  use  ether  almost  exclusively.  Of  all 
those  who  answered  the  questions,  sixty  per  cent,  use  ether,  twen- 
ty-five per  cent,  use  chloroform,  and  fifteen  per  cent,  use  various 
mixtures  of  ether  and  chloroform,  mostly  the  A.  C.  E.  mixture. 
One  hundred  and  twenty-seven  deaths  were  reported  from  anes- 
thesia either  in  their  own  practice  or  known  in  the  practice  of 
others.  Of  these  fifteen  were  from  ether  and  one  hundred  and 
twelve  from  chloroform. 

*  Journal  of  the  American  Medical  Association  for  Dec.  19,  1896. 


38  THE    PRACTICE    OF    DENTAL    MEDICINE. 

Prof.  Roswell  Park  of  Buffalo,  the  only  advocate  of  chloroform 
in  the  East,  when  he  answered  the  foregoing  questions,  said:  "I 
believe  chloroform  equally  as  safe  as  ether  in  proper  hands,  with 
proper  precautions,  and  it  is  otherwise  preferable."  He  says  he 
has  lost  one  patient  on  the  table  from  chloroform,  and  knows  of 
three  or  four  others  that  have  died  in  the  practice  of  other  surgeons 
under  the  same  anesthetic.  He  says:  ''Ether  does  not  kill  as 
many  on  the  table,  but  many  more  afterward,  because  of  various 
complications;  hence  my  preference  for  chloroform." 

Those  who  prefer  chloroform  usually  give  these  reasons: 

1.  It  acts  more  quickly. 

2.  It  is  more  pleasant  to  the  patient. 

3.  It  produces  less  nausea. 

4.  It  is  more  safe  to  use  with  an  artificial  light. 

5.  Its  after-efitects  are  less  injurious. 

Dr.  Caldwell  makes  the  following  comments  concerning  the 
above  reasons : 

As  to  the  first,  he  thinks  the  statement  is  not  well  founded,  for 
he  succeeds,  with  an  improved  inhaler,  in  anesthetizing  the  patient 
with  ether  in  an  average  of  four  and  one-half  minutes. 

Regarding  the  second  point,  he  thinks  that  the  fact  that  chlo- 
roform is  more  pleasant  to  the  patient  should  not  weigh  against  its 
greater  danger. 

The  third  statement,  that  chloroform  causes  less  nausea,  is 
entirely  untrue.  Immediately  on  recovery  from  ether  the  patient 
may  regurgitate  a  small  quantity  of  mucus  from  his  throat,  as  ether 
increases  this,  but  regarding  the  persistent  vomiting  that  occurs 
in  the  next  few  hours  after  anesthesia,  this  is  more  likely  to  occur 
from  chloroform  than  ether,— a  position  which  is  sustained  by 
Hewitt  in  his  work  on  Anesthetics.  Dr.  Caldwell  speaks  of  his 
own  experience,  having  taken  an  anesthetic  more  than  a  hundred 
times;  when  he  took  chloroform  he  usually  vomited  more  or  less 
for  the  next  twenty-four  hours,  while  in  the  case  of  ether,  nausea 
ceased  in  a  short  time. 

In  regard  to  the  danger  of  using  ether  with  artificial  light,  it 
is  asked  why  the  use  of  chloroform  is  not  restricted  to  cases 
operated  on  at  night. 

The  after-effects  of  ether  are  probably  exaggerated,  and  it  is  a 
question  whether  reported  cases  of  bronchial  irritation,  etc.,  would 
not  have  occurred  had  any  other  anesthetic  been  used. 


ADMINISTRATION    OF    ANESTHETIC    AGENTS.  39 

Prof.  Gaillard  Thomas  of  New  York  says:  "Ether!  ether!  ether! 
A  practice  of  forty  years  has  taught  me  that  ether  is  safe  and  effect- 
ual, and  that  chloroform  is  attended  with  great  danger.  I  have 
had  no  deaths  from  chloroform,  but  have  spent  many  a  mauvais 
quart  d'heiirc  in  resuscitating  a  patient  at  the  point  of  death  from 
chloroform." 

Prof.  C.  B.  Penrose  of  Philadelphia  says:  "I  always  use  ether, 
for  I  believe  the  mortality  of  ether  is  very  much  less  than  that  of 
chloroform.  I  believe,  however,  the  danger  from  ether  is  under- 
estimated. It  is  usually  administered  before  a  prolonged  opera- 
tion by  the  most  inexperienced  physician  present,  and  I  think 
many  more  would  survive  prolonged  operations  if  the  anesthetic 
were  administered  by  a  man  of  experience.  I  would  prefer  the  in- 
experienced man  for  an  assistant  and  the  most  experienced  man 
for  the  anesthetizer,  if  I  was  obliged  to  choose.  I  believe  that 
deaths  sometimes  occur  twenty-four  or  forty-eight  hours  after  an 
operation  which  have  been  induced  by  an  improper  administration 
of  the  anesthetic." 

Regarding  the  A.  C.  E.  mixture,  clinical  experience  does  not 
support  its  general  use.  It  may  be  readily  understood  that  the 
mixture  contains  drugs  of  different  volatility,  requiring  different 
methods  of  administration,  and  that  one  can  never  be. sure  of  its 
ingredients. 

Dr.  H.  C.  Wood  says:  "All  these  mixtures  are,  in  my  opinion, 
more  dangerous  than  the  individual  drugs  of  which  they  are  com- 
posed, and  their  use  should  be  positively  eschewed." 

Ethyl  bromid  has  not  yet  succeeded  in  making  its  way  into 
popular  use.  It  has  not  demonstrated  its  superiority  or  safety  over 
chloroform,  although  some  good  statistical  results  have  been 
shown. 

Regarding  mixtures,  it  should  be  said  that  nitrous  oxid  gas  and 
ether  have  been  used  with  success,  usually  beginning  the  adminis- 
tration with  the  nitrous  oxid  and  continuing  with  ether,  although 
the  reverse  of  this  order  has  proved  most  satisfactory. 

Dr.  C.  L.  Schleich  of  Berlin  has  used  a  mixture  for  general 
anesthesia  which  promises  good  results.  The  principle  upon 
which  Dr.  Schleich  bases  his  conclusions  is  that  "The  absorption 
of  a  general  anesthetic  is  chiefly  regulated  by  the  relation  of  the 
temperature  of  the  patient  to  the  boiling-point,  or  point  of  maxi- 
mum evaporation,  of  the  anesthetic.     If  the  point  of  maximum 


40  THE    PRACTICE    OF    DENTAL   MEDICINE. 

evaporation  is  near  to  the  temperature  of  the  patient,  as  much 
will  be  exhaled  during  expiration  as  is  inhaled  on  inspiration." 
The  maximum  evaporating  point  of  chloroform  is  much  higher 
than  that  of  the  body  temperature,  therefore  in  the  use  of  this  agent 
it  will  be  absorbed  by  the  blood  in  larger  quantities  than  is  needed, 
and  it  will  therefore  tax  all  the  parenchymatous  organs  propor- 
tionately in  its  elimination." 

Dr.  Schleich  makes  a  mixture  of  chloroform,  petroleum,  ether, 
and  sulfuric  ether  in  various  proportions,  by  which  he  may 
change  the  boiling-point  of  the  mixture  at  will.  Of  these  agents, 
Dr.  Schleich  has  prepared  three  mixtures,  having  different  boiling- 
points.  Mixture  I.  has  a  boiling-point  equal  to  that  of  the  body, 
which  may  be  employed  in  operations  requiring  a  short  time  only, 
while  the  other  mixtures,  II.  and  III.,  having  a  higher  boiling- 
point,  are  intended  for  longer  operations,  requiring  a  more  pro- 
found anesthesia.  The  method  of  administration  is  on  the  same 
principle  as  with  other  anesthetics,  care  being  exercised  not  to  ad- 
minister an  overdose.  The  formulae  for  these  mixtures  are  as 
follows : 

Mixture  I.      (Boiling-point,  38°   C.) 

Chloroform,  45  parts. 

Petroleum  ether,  15       " 

Sulfuric  ether,  180       " 


Mixture  II.     (Boiling- 

point, 

40° 

c.) 

Chloroform, 

45  parts 

Petroleum  ether. 

15       " 

Sulfuric  ether, 

ISO      " 

Mixture  III.     (Boiling-point,  42°  C.) 

Chloroform,  30  parts. 

Petroleum  ether,  15       " 

Sulfuric  ether,  80 

Dr.  Willy  Meyer,  of  New  York,  reports  favorably  on  the  use 
of  this  solution  in  one  hundred  cases,  in  which  he  notes  that  there 
has  been  but  "little  excitement,  and  rarely  cyanosis;  the  pulse  has 
been  of  excellent  quality;  the  respirations  have  been  unimpaired, 
except  when  the  anesthetizer  has  been  negligent;  there  has  been 
no  hypersecretion  of  mucus,  and  no  consecutive  bronchitis  or 
pneumonia;  vomiting  has  occurred  in  only  forty-four  per  cent.,  and 
albuminuria  in  only  four  per  cent,  of  the  cases;  and  the  return  to 


ADMINISTRATION    OF    ANESTHETIC    AGENTS.       *  4I 

consciousness  has  been  more  rapid  than  after  either  chloroform  or 
ether  narcosis." 

If  chloroform  is  to  be  employed,  it  is  undoubtedly  safer  to  adopt 
the  recent  method  of  admitting  oxygen  with  the  chloroform  vapor. 
The  oxygen  is  made  to  pass  into  a  bottle  containing  chloroform, 
and  the  combined  vapors  are  then  conducted  to  the  patient.  The 
oxygen  is  under  control,  and  may  be  increased  in  amount  as  the 
condition  of  the  patient  demands  it.  When  it  is  desired  to  resus- 
citate the  patient,  pure  oxygen  is  administered.  It  is  claimed  that 
this  method  is  safer  than  the  old  method  of  using  chloroform,  and 
that  it  is  not  accompanied  by  nausea  and  the  other  unpleasant  after- 
effects. 

This  method  should  be  regarded  as  one  in  which  oxygen  is  em- 
ployed as  a  safeguard  only,  and  it  must  be  borne  in  mind  that  its 
employment  does  not  obviate  the  fact  that  chloroform  is  the  anes- 
thetic used,  and  that  dangerous  results  may  yet  occur. 

The  admixture  of  oxygen  with  nitrous  oxid  gas,  as  suggested 
by  Dr.  Hewitt  of  London,  is  a  decided  advance  in  the  administra- 
tion of  the  agent. 

The  Method. — Before  the  question  of  anesthetic,  of  instruments, 
etc.,  comes  that  of  the  anesthetizer  himself.  Has  he  had  expe- 
rience, and  is  he  in  a  proper  physical  condition,  not  only  to  use  the 
best  judgment  in  regard  to  the  varying  conditions  of  the  patient, 
but  to  act  promptly  and  efficiently  in  any  emergency  that  may 
arise?  Is  he  in  every  way  well  prepared  to  cope  with  the  various 
obstructions  to  respiration,  as  occlusion  of  the  glottis  by  any  for- 
eign substance  coming  from  the  stomach,  or  by  the  tongue  falling 
backward,  or  paralysis?  Has  he  shown  himself  skillful  and  wise  in 
meeting  such  dangers  as  heart-failure,  cerebral  hemorrhage,  or 
severe  shock?  The  anesthetizer  should  meet  all  these  require- 
ments, for  he  has  no  light  task  to  perform,  but  one  of  grave  respon- 
sibility, requiring  the  closest  attention  from  the  moment  the  patient 
enters  until  he  passes  from  under  his  care.  While  the  majority  of 
surgeons,  especially  those  connected  with  large  hospitals,  have 
skilled  anesthetizers,  there  is  too  great  a  tendency  to  employ  stu- 
dents and  others  who  are  utterly  unqualified  for  this  important 
work.  The  production  of  anesthesia  should  never  be  entrusted  to 
any  medical  student  who  has  studied  a  little;  a  human  life  is  taken 
in  hand,  and  an  agent  administered  which  is  so  powerful  that  it 
suspends,  one  after  another,  the  various  functions  of  the  body, 


42  THE    PRACTICE    OF    DENTAL    MEDICINE. 

until,  if  continued,  death  takes  place.  Many  times  the  patient 
approaches  death  so  nearly  that  it  requires  the  keenest  observation 
with  the  tenderest  care  on  the  one  hand,  and  instantaneous  action 
with  courage  on  the  other,  to  prevent  a  fatal  result. 

Preparation  for  the  Operation. — Instruments  should  be 
selected  for  the  operation,  and  placed  where  they  may  be  available. 
Besides  the  essential  operative  instruments,  there  should  be  at  hand 
a  mouth-prop,  an  instrument  capable  of  adjustment,  so  as  to  open 
the  jaws  slightly,  or  more,  as  the  case  may  be;  also  a  tongue- 
depressor  and  forceps  for  pulling  out  the  tongue;  an  instrument  or 
instruments  for  the  removal  of  any  foreign  body  that  may  lodge  in 
the  throat,  and  a  hypodermic  syringe.  A  solution  of  carbolic  acid 
1  140  is  also  at  hand,  in  which  to  dip  instruments  or  to  keep  them 
immersed.  Restoratives,  usually  aqua  ammonise  for  inhalation 
and  aromatic  spirits  of  ammonia  for  internal  or  subcutaneous  use, 
brandy  or  whiskey,  and  tablets  of  strychnin  sulfate,  gr.  gV  to 
3^.  It  is  best  to  have  the  strychnin  already  dissolved  and  the 
syringe  charged  with  it. 

When  the  instruments  are  in  readiness,  but  covered  so  as  to 
be  out  of  sight,  the  patient  may  enter.  He  should  be  told  that 
some  anesthetic  is  to  be  administered  to  produce  sleep  and  freedom 
from  pain ;  that  he  need  not  be  afraid,  as  his  welfare  will  be  guarded 
most  carefully;  that  he  will  do  well  to  yield  himself  entirely  to  the 
operator.  With  these  or  other  assuring  words  the  anesthetic 
may  be  administered,  it  being  understood  that  previous  to  this 
time  the  patient's  physical  condition  has  been  ascertained,  and  his 
clothing  loosened.  No  food  should  have  been  taken  for  ten  or 
twelve  hours  at  least.  If  the  patient  is  very  weak  an  enema  of 
peptonized  milk,  with  or  without  some  stimulant,  may  be  adminis- 
tered at  least  two  hours  before  the  operation.  If  the  patient  is 
weak  and  debilitated,  it  is  considered  good  practice  to  inject  sub- 
cutaneously,  gr.  ^  to  :|  of  morphin  and  gr.  y^-g-  to  y^o  o^  atropin 
previous  to  the  inhalation. 

Some  anesthetizers  make  it  a  rule  to  examine  the  heart  and 
respiration  just  previous  to  the  administration;  this  should  always 
be  done  at  some  time,  preferably  at  some  previous  sitting. 

The  hair  should  be  noticed;  combs,  hairpins,  and  earrings 
should  be  removed.  Examine  the  mouth  for  very  loose  teeth, 
or  partial  or  full  sets  of  teeth,  all  of  which  should  be  removed. 

It  is   during  these   preliminaries  that  therapeutic   suggestion 


ADMINISTRATION    OF    ANESTHETIC    AGENTS.  43 

comes  in  to  allay  the  fear  of  the  patient,  and  to  assist  in  the  carry- 
ing out  of  one's  directions.  Begin  with  a  few  words  of  conversa- 
tion, and  by  the  voice  and  manner  of  the  patient  you  may  learn 
much  as  to  his  nervous  condition.  The  degree  to  which  you  may 
carry  these  suggestions  will  be  governed  by  your  own  facility  of 
manner  and  power,  the  needs  of  the  patient,  and  the  circumstances 
in  general. 

The  patient  should  then  be  instructed  how  to  breathe,  after 
which  the  position  should  be  fixed,  this  being  determined  by  the 
anesthetic  used.  With  nitrous  oxid  the  horizontal  position  is 
not  imperative,  as  in  chloroform,  but  a  semi-reclining  position 
may  be  arranged  when  the  operation  will  admit  it.  The  clothing 
about  the  waist  should  always  be  loosened,  whatever  anesthetic 
agent  may  be  used. 

In  administering  nitrous  oxid  it  is  better  to  use  a  mouth-tube, 
one  of  the  older  style,  which  does  not  cover  the  face.  After  the 
patient  is  shown  just  how  to  breathe,  he  is  allowed  to  take  a  few 
inhalations  of  air,  when  the  gas  is  quietly  turned  on.  The  object 
in  having  the  inhaler  above  mentioned  is  three-fold:  First,  it 
enables  the  operator  to  see  more  of  the  patient's  face,  and  thereby 
to  regulate  the  passage  of  air  through  the  nose,  or  the  proper 
amount  of  oxygen  into  the  inhaler.  Second,  the  patient  must  feel 
less  as  if  he  were  being  smothered  than  when  a  hood  is  placed  over 
the  face. 

Whenever  it  is  practicable,  the  upper  and  lower  jaws  should 
be  separated  and  maintained  in  this  position  by  means  of  a  suitable 
prop,  for  the  reason  that  there  is  usually  more  or  less  rigidity,  and 
the  period  of  anesthesia  being  short  the  operator  has  no  time  to 
waste  in  trying  to  open  the  jaws.  With  the  prop  in  position,  the 
tube  is  placed  in  the  mouth  and  the  patient  instructed  to  close  the 
lips  over  it;  if  it  is  his  first  experience,  and  there  is  difliculty  in 
obtaining  a  deep  respiration,  good  results  may  be  obtained  by 
asking  the  patient  to  blow  as  upon  a  trumpet;  this  is  necessarily 
followed  by  a  deep  inspiration.  Upon  the  first  indications  of  dis- 
coloration of  the  face,  let  in  a  little  air,  or  oxygen,  and  regulate 
it  according  to  the  appearance  of  the  face.  The  patient  may  be 
asked  if  the  effects  are  beginning  to  be  felt,  and  the  operator  may 
judge  by  the  response.  When  no  response  is  made  and  the  breath- 
ing begins  to  be  heavy  and  stertorous,  the  anesthetic  should  be 
withdrawn. 


44  THE    PRACTICE    OF    DENTAL    MEDICINE. 

For  ether  anesthesia  the  face  should  be  anointed  with  vasehn 
for  the  protection  which  it  affords  the  skin.  Do  not  begin  by 
pouring  on  a  large  quantity  of  ether,  crowding  the  inhaler  over  the 
face  and  forcing  the  inhalation  at  this  point;  rather  let  the  patient 
breathe  through  the  inhaler  a  moment  without  the  anesthetic,  then 
add  a  few  drops  at  a  time,  gradually  increasing  the  amount  until 
the  maximum  quantit}^  is  used. 

The  stage  or  extent  to  wdiich  anesthesia  shall  be  carried  de- 
pends upon  the  length  of  time  the  operation  is  to  consume,  the  part 
of  the  body  to  be  operated  on,  the  gravity  of  the  operation,  and  the 
condition  of  the  patient.  Short  operations,  like  opening  an  abscess 
or  extracting  a  tooth,  would  require  only  the  primary  stage,  which 
often  arrives  quickly  and  which  is  known  by  asking  the  patient 
some  question  or  to  do  something.  If  there  is  no  response,  it  may 
be  concluded  that  the  primary  stage  has  been  reached.  If  the 
operation  is  on  the  eye,  or  is  some  difficult  operation  between  the 
jaws,  or  on  the  bladder,  the  full  relaxation  of  the  third  stage  should 
be  attained.  The  condition  of  the  patient  may  require  a  modifica- 
tion of  these  requirements  in  any  stage.  If  the  operation  is  upon 
the  throat,  or  naso-pharynx,  the  patient  should  be  carried  beyond 
the  stage  of  excitement,  but  only  just  be3^ond  it,  it  being  desirable 
to  obtain  as  light  anesthesia  as  possible  consistent  with  a  painless 
operation.  The  reason  is  that  if  reflex  irritability  of  the  pharynx 
is  destroyed,  blood  or  other  material  may  get  into  the  trachea. 

For  operating  in  the  mouth  or  associate  parts.  Prof.  Thomas 
Fillebrown  of  Boston  has  devised  an  excellent  apparatus  for  main- 
taining anesthesia  at  just  the  desired  point,  while  the  operation  is 
going  on.  It  is  described  as  follows:  A  bellows,  connected  by 
rubber  tubing  with  the  long  tube  of  a  twelve-ounce  wash-bottle, 
with  a  stopcock  intervening  to  regulate  the  flow  of  air.  From  the 
bottle  extends  a  half-inch  rubber  tube  to  the  patient.  The  bottle 
is  filled  one-third  full  of  ether.  The  air  passing  over  the  ether  is 
discharged  through  the  second  tube  a  few  inches  from  the  patient's 
face.  Dr.  Fillebrown  has  found  that  if  the  administration  is  pro- 
longed, the  temperature  within  the  bottle  becomes  so  reduced  that 
the  air  is  not  saturated,  requiring  the  warmth  of  the  hand  or  a 
cloth  applied  to  the  bottle  so  that  the  temperature  shall  not  be 
below  60°  F. 

The  effect  of  anesthetics  upon  the  body  is  gradual,  and  the 
different  stages  are  usually  classified  as  follows: 


ADMINISTRATION    OF    ANESTHETIC    AGENTS.  45 

1.  A  preliminary  stage  of  excitement,  which  may  vary  much 
according  to  the  temperament  of  the  patient.  Tnis  is,  with  ether, 
followed  by  a  very  short  period  of  anesthesia. 

2.  A  stage  of  excitement,  which  also  varies  with  the  individual. 

3.  A  stage  of  relaxation,  unconsciousness,  and  insensibility  to 
pain. 

In  the  stage  of  excitement  there  are  often  violent  demonstra- 
tions on  the  part  of  the  patient.  The  respirations  are  rapid,  the 
face  is  flushed,  the  eyes  are  staring,  the  muscles  rigid;  and  in  those 
of  an  extremely  nervous  temperament,  or  in  alcoholics,  a  belliger- 
ent attitude  may  be  taken,  and  the  delirium  may  otherwise  be 
fierce  and  prolonged.  The  remedy  for  this  is  to  push  the  anes- 
thetic, controlling  the  patient  as  best  you  may,  but  without  force 
if  possible. 

When  the  third  stage  has  been  reached,  the  patient  does  not 
respond  to  the  passing  of  the  fingers  over  the  eyelashes,  or  to 
touching  the  conjunctiva.  If  the  arm  or  leg  be  now  raised,  it  drops 
without  resistance,— there  is  complete  relaxation.  When  these 
conditions  are  obtained,  the  patient  is  ready  for  operation.  If 
anesthesia  is  carried  farther  than  this  stage  the  patient's  life  is  in 
jeopardy. 

The  Treatment  of  Unfavorable  Conditions  during  and 
AFTER  Anesthesia. — During  the  administration  of  an  anesthetic 
and  the  performance  of  the  operation,  and  until  the  patient  has 
fully  recovered,  the  anesthetizer  should  be  on  the  alert  for  un- 
favorable symptoms  from  every  possible  source.  Nothing  relating 
to  the  patient's  condition  should  escape  his  notice.  It  is  not 
enough,  during  the  administration  of  ether,  to  watch  the  respira- 
tion only,  on  the  principle  that  so  long  as  breathing  is  maintained 
the  patient  is  safe;  one  must  watch  everything.  It  may  be  noticed 
that  the  face  is  becoming  discolored,  and  the  breathing  irregular 
and  noisy;  this  is  a  symptom  which  indicates  an  obstruction  to 
breathing,  and  it  may  occur  from  nervous  spasm,  or  reflex  action 
due  to  the  irritating  action  of  the  anesthetic  in  the  throat.  It  may 
also  occur  from  the  direct  action  of  the  anesthetic  upon  the  respira- 
tory centers,  from  mucus  or  some  foreign  body  which  has  become 
lodged  in  the  throat,  or  it  may  be  due  to  some  unusual  position  of 
the  body;  for  example,  the  head  may  be  thrown  forward  so  that  the 
chin  rests  upon  the  chest,  thus  seriously  impeding  respiration. 

It  has  been  stated  that  incomplete  or  partial  anesthesia  is  a 


46  THE    PRACTICE    OF    DENTAL    MEDICINE. 

source  of  danger  during  the  performance  of  an  operation,  and  the 
position  taken  is  a  reasonable  one,  but  it  is  apt  to  be  confused 
with  the  primary  stage.  Primary  anesthesia,  while  it  lasts,  is  quite 
complete,  and  short  operations  may  be  done  without  pain.  In 
many  instances  it  is  quite  impossible  to  induce  primary  anesthesia, 
the  patient's  sensibilities  remaining  fully  alive  until  the  exciting 
stage  is  reached.  In  such  cases,  therefore,  it  would  be  manifestly 
unwise,  as  well  as  dangerous,  to  inflict  pain.  In  view  of  these 
considerations  it  is  obvious  that  this  danger  may  be  avoided  by 
securing  full  anesthesia  before  beginning  the  operation. 

Treatment  of  Obstructions  to  Breathing. — Respiration  may  be 
impeded  by  nervous  spasm,  and  if  the  patient  be  hypersensitive 
the  best  treatment  is  prophylactic,  and  may  consist  in  the  adminis- 
tration of  sodium  bromid,  5  grains,  three  times  during  the  pre- 
vious day,  and  10  grains  half  an  hour  previous  to  the  operation. 
But  in  cases  of  nervous  spasm  during  the  administration  of  an 
anesthetic,  the  agent  should  be  withdrawn  and  re-administered  in 
a  more  gradual  manner.  This  is  precisely  the  thing  to  be  done  in 
a  case  of  suspended  breathing  from  the  direct  action  of  the  anes- 
thetic upon  the  respiratory  centers.  If  mucus  collects  in  the 
throat,  it  should  be  removed  by  turning  the  patient  over,  face 
downward,  or  by  swabbing  the  throat  by  means  of  properly  shaped 
forceps  armed  with  absorbent  cotton  or  antiseptic  sponge. 

If  a  tooth  or  other  foreign  body  becomes  lodged  in  the  throat 
it  is  better  to  first  turn  the  patient  over  on  the  face,  and  if  the 
foreign  body  does  not  fall  out,  insert  the  finger  in  the  throat, 
sweeping  it  from  side  to  side  in  order  to  bring  out  the  substance. 
These  methods  failing,  resort  must  be  had  to  laryngeal  forceps  or 
other  instruments  for  this  purpose. 

In  cases  of  impeded  respiration  due  to  the  improper  position 
of  the  body,  it  should  be  understood  that  in  order  to  have  free 
respiration  the  chin  should  be  thrown  well  back  from  the  breast, 
the  tongue  should  not  be  allowed  to  drop  back  into  the  throat,  and 
that  as  a  remedy  for  this  the  angle  of  the  lower  jaw  may  be  pushed 
forward. 

Another  condition  of  danger  is  failure  of  the  heart,  as  indicated 
by  its  pulsation  becoming  weak  and  irregular,  and  by  the  growing 
pallor  of  the  face.  In  such  a  condition  the  anesthetic  should  be 
withdrawn  at  once,  the  head  lowered,  the  respiration  stimulated  by 
the  application  of  aqua  ammonije  to  the  nose,  and  if  necessary  a 


ADMINISTRATION    OF   ANESTHETIC    AGENTS.  4/ 

subcutaneous  injection  of  strychnin,  gr.  -^,  or  twenty  drops  of 
aromatic  spirits  of  ammonia,  or  a  dram  of  brandy  should  be 
given,  or  oxygen  gas  may  be  administered  by  inhalation.  If  the 
heart-failure  persists,  the  patient  must  be  inverted,  or  artificial 
respiration  tried.  A  powerful  stimulant  to  the  respiration  and 
circulation  consists  in  turning  the  patient  face  downward,  and  ap- 
plying the  end  of  a  towel  wet  in  cold  water  to  the  spine  between 
the  shoulderblades,  by  the  method  of  flagellation.  Manual  dilata- 
tion of  the  sphincter  ani  also  has  a  powerful  reflex  action  in  stimu- 
lating respiration. 

Some  of  the  following  conditions  demand  watchfulness  and  a 
temporary  withdrawal  of  the  anesthetic: 

A  gasping  respiration,  in  which  the  mouth  is  opened  widely  and 
the  air  drawn  in  convulsively,  is  to  be  regarded  as  indicative  of 
some  serious  disturbance;  3.  stertorous  respiration  should  be  closely 
watched,  and  the  anesthetic  removed  accordingly. 

Hiccough  has  been  regarded  as  a  grave  symptom,  and  the  anes- 
thetizer  should  either  wholly  or  partially  withdraw  the  anesthetic 
in  every  case  until  the  hiccough  ceases. 

If  nausea  or  vomiting  occurs  from  the  administration  of  an 
anesthetic  it  may  as  well  be  encouraged  until  it  is  over,  for  the 
stomach  is  almost  sure  to  rid  itself  of  its  contents  sooner  or  later. 

A  rapid  dilatation  of  the  pupil  indicates  collapse. 

After-Effects. — The  cerebral  congestion  which  is  induced  to  a 
greater  or  less  extent  by  ether  narcosis  is  often  sufficient  to  pro- 
duce a  severe  headache,  which  in  many  cases  passes  away  in  a 
short  time,  but  in  others  is  more  or  less  persistent.  In  such  cases 
the  object  is  to  reduce  the  amount  of  blood  in  the  brain  and  to 
increase  the  amount  in  the  lower  extremities.  This  may  be 
effected  by  cold  applications  to  the  head  and  warmth  to  the  feet. 

Often  a  full  dose  of  morphin  acts  with  benefit  in  these  cases  by 
controlling  the  nausea  and  vomiting  which  usually  accompany 
headache.  Another  remedy,  often  efficacious  in  vomiting  from 
any  cause,  is  sodium  bromid  in  minute  doses;  -|  of  a  grain  may  be 
placed  on  the  tongue  and  washed  down  with  a  swallow  of  water; 
this  to  be  repeated  every  fifteen  minutes. 

Hysteria  in  its  various  forms  may  often  follow  the  administra- 
tion of  an  anesthetic,  and  it  should  be  promptly  met  with  the 
proper  treatment. 

Local  Anesthesia. — Since  the  introduction  of  cocain  and  its  anes- 


48  THE    PRACTICE    OF    DENTAL    MEDICINE. 

thetic  property  became  generally  known,  in  1884,  local  anesthesia 
has  been  increasingly  employed.  There  are  two  fundamental 
methods  by  which  it  may  be  produced;  one  in  which  the  parts  are 
anesthetized  by  means  of  extreme  cold  produced  by  freezing  mix- 
tures and  evaporating  spray,  and  the  other,  by  bringing  some  drug 
having  local  anesthetic  properties  in  contact  with  the  terminal  fila- 
ments of  sensory  nerves.  Extremes  of  cold  or  heat  may  produce 
local  insensibility  to  pain,  but  cold  has  been  most  frequently  em- 
ployed. 

Ethyl  chlorid,  sulfuric  ether,  and  various  combinations  of 
ether,  chloroform,  and  alcohol,  have  been  frequently  used  as  a 
spray  to  produce  local  anesthesia. 

Heat,  in  the  form  of  hot  air  or  steam,  has  been  used  principally 
in  the  obtunding  of  hypersensitive  dentin.* 

There  are  manv  drugs  having  a  local  anesthetic  effect  by  means 
of  their  paralyzing  influence  on  the  terminal  filaments  of  the  sen- 
sory nerves,  and  they  may  be  applied  to  the  surface  or  injected  into 
the  tissue,  but  the  parenchymatous  injection  is  by  far  the  most 
effective.  Such  drugs  are  carbolic  acid,  tincture  of  aconite  root, 
eucain  hydrochlorid,|  cocain  hydrochlorid,  tropacocain,  etc. 

Tropacocain  is  said  to  have  advantages  over  cocain,  it  being 
less  toxic,  but  cocain  is  by  far  the  most  useful;  it  may  be  applied 
to  the  surface  of  mucous  membranes  and  absorption  will  take  place 
in  different  degrees  with  proportionate  anesthesia.  This  is  not 
true  when  applied  to  the  skin,  the  subcutaneous  injection  being 
necessary  in  such  cases.  In  situations  in  which  it  is  diiTficult  to 
secure  complete  anesthesia,  resort  may  be  had  to  cataphoresis| 
or  to  the  parenchymatous  injection. 

While  cocain  is  to  be  commended  as  the  best  local  anesthetic, 
it  should  be  known  that  it  is  a  powerful  drug,  and  therefore  must 
be  used  intelligently  and  with  great  caution.  Extensive  applica- 
tions to  the  surface  of  the  interior  of  the  mouth,  nose,  or  pharynx 
should  not  be  made,  even  with  a  solution  containing  but  four  per 

*  See  chapter  on  Hypersensitive  Dentin. 

t  The  writer's  experiments  on  the  lower  animals  show  that  eucain  is 
more  toxic  than  cocain.  In  the  human  mouth,  however,  in  therapeutic 
amounts,  no  toxic  symptoms  have  appeared;  but,  with  the  same  number 
of  administrations,  as  much  can  be  said  of  cocain.  Eucain  is  not  so  effec- 
tive as  cocain  when  simply  applied  to  mucous  membranes. 

:|:  See  chapter  on  Hypersensitive  Dentin. 


ADMINISTRATION    OF    ANESTHETIC    AGENTS.  49 

cent,  of  cocain,  but  greater  caution  should  be  used  when  injecting 
this  drug.     The  full  dose  should  not  exceed  -|  of  a  grain. 

But  cocain  is  the  more  readily  to  be  commended  now,  in  view 
of  the  fact  that  solutions  of  this  drug  may  be  made  effectual  while 
containing  only  i  part  to  500  or  1000  of  water.  This  fact  was 
brought  out  by  Reclus,  and  later  by  Dr.  C.  L.  Schleich  of  Berlin, 
who  has  further  developed  the  method  of  producing  local  anes- 
thesia. Dr.  Schleich  showed  that  the  injection  of  a  solution  of  salt 
and  other  drugs  had  an  anesthetic  effect,  dependent  upon  the  dis- 
tension or  infiltration  of  the  tissues  with  the  solution.  He  found 
practically  that  cocain  was  essential  in  order  to  make  the  injection 
itself  painless.      Dr.  Schleich  made  use  of  three  different  solutions 


as  follows : 

Strong: 

Cocain  hydrochlorid, 

gr.  3: 

Morphin  sulfate, 

gr.Vs; 

Sodium  chlorid. 

gr-  3; 

Saturated  boric  acid  solution, 

5  3V2. 

(or,  \yater,  5  3^2,  carbolic  acid, 

"KtV.) 

Normal: 

Cocain  hydrochlorid. 

gr.  iK- 

Morphin  sulfate, 

gr.Vs; 

Sodium  chlorid, 

gr.  3; 

Saturated  boric  acid  solution, 

0  s'A. 

(or,  Water,  o  3^,  carbolic  acid,       ''Vl  iV-) 

Weak:        Cocain  hydrochlorid,  gr.  %; 

Morphin  sulfate,  gr.  xV  ; 

Sodium  chlorid,  gr.  3; 

Saturated  boric  acid  solution,  3  sVi. 

(or,  Water,  §  3H,  carbolic  acid,  "KrV •) 

The  recent  use  of  weak  solutions  of  cocain  in  this  country  has 
demonstrated  that  a  solution  containing  i  part  of  cocain  to  500  of 
distilled  water''-  is  sufficient  to  produce  complete  local  anesthesia 
under  proper  conditions. 

The  technique  of  the  operation  to  produce  local  anesthesia  by 
parenchymatous  injection  should  be  very  carefully  observed  in 
order  to  insure  success.  It  is  in  substance  as  follows:  The  parts 
into  which  the  injections  are  to  be  made  should  be  cleansed  with 
some  antiseptic  wash;  the  syringe  should  be  strong,  with  a  fine 
needle  point,  reinforced  for  half  its  length;  it  should  be  aseptic, 
having  been  washed  with  a  two  per  cent,  solution  of  formaldehyde. 

*  The  "normal  salt  solution,"  made  by  dissolving  a  scant  teaspoonful  of 
sodium  chlorid  to  a  pint  of  water,  may  be  used  instead  of  plain  water. 

5 


50  THE    PRACTICE    OF    DENTAL    MEDICINE. 

The  syringe  may  now  be  filled  and  the  air  expelled  by  pointing  the 
needle  directly  upward,  and  pressing  upon  the  piston  until  the 
liquid  appears.  The  direct  application  of  a  strong  solution  of 
cocain  or  carbolic  acid  at  the  point  where  the  needle  is  to  be  first 
inserted  will  enable  the  operator  to  introduce  the  needle  with  but 
little  pain.  The  needle  is  firmly  introduced  with  the  aperture 
toward  the  tissue,  just  beneath  the  surface,  and  a  very  little  solu- 
tion injected;  wait  a  few  seconds,  then  thrust  the  needle  in  a  little 
farther  and  inject  more.  Now  withdraw  the  needle  and  introduce 
it  just  within  the  wheal,  or  circle  of  infiltated  tissue  which  you  have 
been  careful  to  make,  and  inject  again,  making  as  large  a  wheal  as 

Fig.  6. 


Method  of  injecting  anesthetic. 

practicable,  and  so  on  until  the  entire  area  which  it  is  desirable  to 
anesthetize  has  been  saturated  with  the  solution.  The  operation 
may  then  be  conducted  within  the  infiltrated  area. 

The  method  of  injecting  anesthetic  agents  for  the  extraction 
of  teeth  is  illustrated  in  Fig.  6.  Even  with  very  weak  solutions, 
the  operator  should  be  careful  not  to  inject  beyond  the  gum  tissue 
into  the  soft  vascular  structures  of  the  cheek,  or  those  in  the 
vicinity  of  the  third  molar. 

Some  of  the  opeiations  about  the  soft  tissues  of  the  mouth  to 
which  local  anesthesia  is  especially  adapted  are,  for  example, 
lancing  the  gum,  cutting  away  gum  tissue  overlying  lower  third 
molars,  making  an  artificial  fistula,  extracting  teeth,  removing 
dental  pulps,  etc. 


menstruation;  pregnancy.  51 

CHAPTER    VII. 
MENSTRUATION;  PREGNANCY. 
MENSTRUATION. 

Synonyms. — Catamenia;  Monthly  sickness;  Periods;  Flowing; 
Menses. 

Definition. — A  periodical  discharge  of  blood  from  the  uterus, 
occurring,  as  a  rule,  once  in  twenty-eight  days.  During  preg- 
nancy and  lactation  this  process  is  usually  suspended. 

First  Appearance. — The  first  appearance  of  the  menses  cor- 
responds with  what  is  known  as  the  age  of  puberty,  which  marks  a 
period  of  active  physical  development  in  certain  directions,  and 
indicates  the  ability  to  conceive  and  bear  children. 

Race  and  climate  appear  to  have  an  influence  over  the  appear- 
ance of  the  menstrual  flow,  while  other  factors  may  also  act  to 
cause  an  appearance  of  the  menses  in  infancy,  or  to  delay  it  until 
adult  life,  but  the  average  age,  in  temperate  climates,  is  fifteen. 

Duration. — In  healthy  women  the  flow  usually  occurs  with 
great  regularity,  and  many  are  able  to  foretell  its  appearance 
almost  to  an  hour.  The  discharge  lasts,  as  a  rule,  about  four 
days,  but  the  time  varies  greatly,  even  in  health. 

Effects  upon  the  General  System. — The  vascular  excitement 
attending  the  menstrual  flow  cannot  fail  to  influence  the  entire 
system.  The  nervous  system  is  especially  affected.  Irritability  of 
mind  and  general  nervous  excitement  render  the  woman  extremely 
sensitive  under  dental  and  other  operations.  While  the  general 
sympathy  and  disturbance  vary  greatly  in  different  persons,  this 
period  should  be  avoided,  if  possible,  in  making  appointments  for 
dental  sittings. 

With  these  considerations  in  mind  it  is  evident  that  the  dentist 
should  follow  a  woman's  own  suggestions  as  to  the  best  time  for 
an  appointment;  and,  if  necessary,  should  advise  that  it  be  made 
for  a  time  when  she  is  feeling  at  her  best,  as  the  operations  will 
then  be  easier  to  bear.  Severe  cases  of  painful  or  profuse  men- 
struation need  not  be  considered  here,  as  the  patient  at  such 
periods  is  incapable  of  keeping  a  dental  appointment. 


52  THE    PRACTICE    OF    DENTAL    MEDICINE. 

Vicarious  Menstruation. — The  possibility  of  vicarious  menstrua- 
tion from  the  mouth  should  be  known,  although  it  is  of  rare  occur- 
rence. The  most  frequent  seat  of  vicarious  menstruation  is  the 
nose,  and  nearly  as  often  the  gums.  The  flow  of  blood  may  come 
from  the  stomach,  or  lungs,  and  in  each  case  it  may  be  seen  in 
the  mouth  without  positive  knowledge  as  to  its  source. 

In  these  cases  of  suspected  vicarious  menstruation  coming 
from  the  mouth,  means  to  check  the  flow  should  be  made  with 
great  circumspection,  medical  advice  being  obtained. 

PREGNANCY. 

Effect  upon  the  Greneral  System. — Pregnancy,  like  dentition,  is, 
in  a  healthy  person,  a  physiological  process,  but  often  one  of 
excessive  activity,  and  so  closely  bordering  on  the  abnormal  that 
the  slightest  irritating  cause  is,  in  proportion  to  the  susceptibility, 
sufficient  to  put  in  motion  a  pathological  process.  With  this 
excessive  physiological  activity,  the  intimate  nervous  connection 
between  the  generative  organs  and  other  parts  of  the  body  is 
shown  in  many  ways;  for  example,  in  the  morning  sickness  which 
is  sometimes  so  severe  as  to  imperil  life ;  in  strange  fancies,  undue 
fear,  abnormal  sensitiveness  of  the  entire  nervous  system,  depraved 
appetite,  etc.  With  these  conditions  prevailing  in  greater  or  less 
degree,  there  is  frequently  added  actual  disease,  either  in  the  repro- 
ductive organs  or  in  other  parts  of  the  body,  which  aggravates 
every  symptom  and  predisposes  the  system  to  various  pathological 
processes. 

Operations  during  Pregnancy. — With  the  foregoing  premises  in 
view,  there  is  only  one  conclusion  to  follow,  viz.  to  avoid  operations 
of  a  surgical  nature  in  every  case,  unless  by  so  doing  there  may  be 
greater  injury  and  disturbance.  Often  there  may  be  a  modifica- 
tion of  usual  dental  operations  so  that  the  teeth  may  be  put  in  a 
comfortable  and  safe  condition  until  the  patient  is  in  a  suitable 
state  of  health  to  bear  whatever  may  be  required. 

When  surgical  operations  are  imperative,  and  the  patient  is 
sensitive  and  fearful,  it  is  wise  not  only  to  assure  the  patient  by 
suggestion,  but  to  administer  some  sedative,  such  as  sodium 
bromid.  If  a  more  powerful  remedy  is  needed,  "chlorodyne"  is 
an  efificient  remedy,  but  as  the  different  formulae  of  this  preparation 
vary  greatly  in  strength,  care  should  be  taken  to  discriminate 
between  them.     If  sodium  bromid  is  prescribed  it  may  be  admin- 


menstruation;  pregnancy.  53 

istered  two  days  before  the  sitting,  with  a  maximum  dose  a  half- 
hour  before  the  operation.  As  a  rule,  the  patient  is  more  suscepti- 
ble to  harm  from  operations  during  the  third,  fourth,  and  eighth 
months  of  pregnancy. 

Anesthetics  during  Pregnancy. — There  seems  to  be  no  reason- 
able ground  for  withholding  an  anesthetic  from  the  pregnant 
patient;  moreover,  it  would  be  cruel,  barbarous,  and  unscientific 
not  to  afford  the  means  of  alleviating  pain  and  shock.  Of  this 
there  should  be  no  question,  especially  as  it  has  never  been  shown 
that  the  ordinary  anesthetics  have  any  poisonous  or  other  injurious 
effect  upon  mother  or  child. 

There  has  been,  and  still  is,  a  difference  of  opinion,  however,  as 
to  the  extent  to  which  anesthesia  should  be  carried.  This  may  be 
left  to  the  good  judgment  of  the  operator,  although  it  may  be  said 
that  the  profound  anesthesia  of  the  third  stage  is  rarely  required. 
In  severe  operations,  therefore,  an  anesthetic  should  be  used  in 
order  to  avoid  pain,  fear,  and  shock;  yet  while  ether  and  nitrous 
oxid  have  each  been  administered  to  pregnant  patients  with  safety, 
it  is  best  to  avoid  the  operation  and  the  anesthetic  in  every  case 
when  one  is  not  forced  by  existing  circumstances  to  proceed. 

Possible  Results  of  Operations  during  Pregnancy. — The  effects 
of  dental  operations  upon  a  pregnant  woman  may  be  two-fold:  i. 
Abortion,  miscarriage,  or  premature  labor.  2.  Some  injurious 
effect  upon  the  fetus  or  upon  the  mother. 

To  know  in  any  case  if  any  of  the  above-mentioned  results  are 
to  take  place  is  impossible;  but  a  full  knowledge  of  the  pregnant 
condition,  as  it  exists  in  the  average  womian,  should  teach  the 
operator  to  avoid,  in  every  case,  any  procedure  which  is  likely  to 
injure  either  mother  or  child,  for  the  reason  that  it  is  impossible 
to  measure  the  susceptibility  of  each  patient. 

Women  have  aborted  when  every  possible  precaution  was  taken 
to  prevent  it,  and  several  cases  are  known  in  which  women  have 
failed  to  bring  about  abortion  after  having  tried  in  various  ways  to 
produce  this  result. 

Anything  which  makes  a  profound  impression  on  the  nervous 
system,  either  by  shock,  pain,  or  fright,  may  affect  either  mother 
or  child  in  various  ways.  It  may  have  an  indefinite,  though  decid- 
edly irritating  effect  upon  the  general  nervous  system,  which  may 
result  in  abortion. 

Of  those  causes  likely  to  occur  in  connection  with  dental  opera- 


54  '    THE    PRACTICE    OF    DENTAL    MEDICINE. 

tions,  severe  toothache  itself  may  be  one.  The  patient  may  receive 
a  fright  through  the  carelessness  of  the  dentist  in  conversation,  or 
from  the  manner  of  operating,  or  from  the  length  of  time  it  con- 
sumes. The  mere  act  of  taking  an  anesthetic,  together  with  its 
effects,  may  produce  abortion  or  premature  delivery,  but  it  is 
doubtful  if  a  pure  anesthetic  has  any  poisonous  effect  on  the  blood. 

Effects  of  Pregnancy  on  the  Teeth. — The  most  potent  cause  of 
ill  effects  upon  the  teeth  as  the  result  of  the  gravid  condition  lies 
in  the  fact  that  many  childbearing  women  are  not  equal  to  the 
task  of  supplying  nutriment  for  themselves  and  the  fetus  m  utcro, 
which  develops  and  grows  entiiely  by  drawing  all  the  necessary 
nutrient  materials  for  bone,  muscle,  and  nerve  from  the  circulation 
of  the  mother.  There  is  also,  in  many  cases,  hyperacidity  of  the 
saliva.  The  deranged  nervous  system  which  accompanies  this 
condition  to  a  greater  or  less  degree  may  so  affect  digestion  and 
assimilation  that  the  blood  is  impoverished  and  the  teeth  are  not 
properly  nouiished.  This  failuie  to  supply  the  necessary  materials 
and  vitality  to  the  teeth  renders  them  susceptible  to  the  acid-pro- 
ducing organisms  of  the  mouth,  and  decay  is  the  result. 

Treatment. — For  the  local  acidity,  alkaline  washes  of  lime- 
water,  a  strong  solution  of  bicarbonate  of  soda,  or  "milk  of  mag- 
nesia" may  be  used  for  frequently  rinsing  the  mouth.  It  may  be 
advisable  and  even  necessary  to  prescribe  the  use  of  some  antacid 
internally;  for  instance,  "Saratoga  Vichy  water,"  an  agreeable  and 
efficient  table  water,  which  may  be  used  freely,  a  pint  at  each  meal, 
or  at  two  meals  in  the  day.  The  other  indication,  viz.  the  insuffi- 
cient supply  of  lime-salts,  may  be  met  in  two  general  ways:  i. 
The  improvement  of  the  general  health  in  every  possible  way,  so 
that  the  lime  contained  in  the  ordinary  food  may  be  assimilated. 
2.  The  administration  of  some  preparation  of  lime,  such  as  the 
lactophosphate.  Fellows'  or  Gardner's  syrup  of  the  phosphates  of 
lime  and  soda. 


CHAPTER    VIII. 

HEMORRHAGE. 

Synonym. — Bleeding. 

Definition. — Escape  of  blood  from  the  body  or  from  the  usual 
channels  in  which  it  is  confined. 


HEMORRHAGE.  '  55 

Etiology. — Cases  of  persistent  hemorrhage  within  the  oral 
cavity  occur  most  frequently  as  the  result  of  the  extraction  of  teeth. 
Occasionally  hemorrhage  may  occur  from  the  breaking  down  of 
necrotic  tissues,  or  from  a  wound  caused  by  a  fractured  tooth,  or 
traumatism  from  any  other  cause.  These  may  be  considered 
direct  or  immediate  causes  of  hemorrhage,  and  as  such  they  have 
very  little  to  do  with  the  serious  and  sometimes  alarming  hemor- 
rhage which  depends  upon  some  predisposing  or  constitutional 
cause.  A  certain  amount  of  hemorrhage  following  an  operation  or 
a  traumatic  injury  is  not  injurious,  and  needs  no  artificial  assistance 
to  check  it;  therefore  any  flow  of  blood  not  excessive  should  be 
left  to  itself,  as  hemostatics  or  appliances  do  harm  rather  than  good 
in  such  cases.  It  is  the  predisposing  or  underlying  cause  that  is  to 
be  considered  as  serious,  and  it  is  the  continued  or  secondary,  and 
not  necessarily  the  primary  hemorrhage  which  causes  alarm. 

It  is  very  often  the  case,  when  we  have  controlled  bleeding  and 
are  congratulating  ourselves  upon  the  success  that  has  attended 
our  efforts  and  the  permanence  which  is  likely  to  follow  as  a  conse- 
quence, that  a  hemorrhage  unexpectedly  recurs  of  a  more  serious 
nature  than  the  one  preceding  it.  This  is  so  common  an  occur- 
rence as  to  have  been  classed  as  secondary  hemorrhage.  It  may 
occur  at  various  periods,  from  that  of  a  few  hours  after  the  opera- 
tion to  days  and  even  weeks.  It  is  not  necessarily  preceded  by 
primary  hemorrhage,  but  may  come  on  when  the  loss  of  blood  in 
the  first  instance  was  insignificant,  and  when  everything,  so  far  as 
the  results  attained  were  concerned,  gave  promise  of  a  most  favor- 
able issue. 

There  are  certain  styptics  which  are  to  be  avoided  in  some 
cases,  as  being  either  direct  or  indirect  causes  of  secondary  hemor- 
rhage; for  example,  "Monsel's  solution"  of  the  persulfate  of  iron, 
although  possessing  many  valuable  qualities  as  a  styptic,  has  one 
serious  objection,  and  that  is,  injury  to  the  part  to  which  it  is 
applied.  If  the  wound  be  of  any  great  extent,  it  is  quite  likely  to 
cause  sloughing  of  the  parts,  thus  inducing  secondary  hemorrhage. 

Hemophilia,  or  what  is  known  as  a  hemorrhagic  diathesis,  is  a 
peculiar  constitutional  condition  which  seems  to  consist  in  a  want 
of  contractility  of  the  vessels  and  the  absence  of  coagulability  of  the 
blood.  The  blood  in  this  variety  of  hemorrhage  oozes  from  the 
part  like  water  from  a  sponge,  its  color  being  neither  scarlet  nor 
dark,  but  intermediate  between  the  two;  it  may  not  be  excessive  in 


56  THE    PRACTICE    OF    DENTAL   MEDICINE. 

quantity  at  first,  but  may  be  checked  for  a  time  and  reappear  again 
after  several  hours.  There  seems  to  be  no  obvious  fault  with  the 
blood  that  issues  from  the  recent  wound;  it  coagulates  after  flowing 
off,  though  it  does  not  do  so  to  any  amount  in  the  wound  itself, 
and  it  possesses  an  equal  quantity  of  fibrin  in  this  diathesis  with 
that  in  the  blood  from  other  persons;  but  as  the  hemorrhage  con- 
tinues this  character  of  the  blood  is  lost,  it  no  longer  coagulates, 
it  becomes  thin  and  watery,  and  leaks  forth  more  readily  if  not 
more  abundantly  than  before. 

It  is  sometimes  observed  that  the  characteristics  of  a  hemor- 
rhagic diathesis  may  be  induced  in  a  previously  healthy  person  by 
privation  of  fresh  air,  light,  and  nourishment,  and  by  confinement 
in  a  low,  damp  situation;  but  that  they  disappear  upon  placing  the 
patient  in  conditions  favorable  to  health ;  this  condition  is,  however, 
nearly  always  inherited,  in  fact  there  are  few  if  any  diseases  with 
so  marked  a  tendency  to  hereditary  transmission. 

Fortunately  persons  with  this  tendency  to  bleed  generally  be- 
come aware  of  the  fact  before  they  reach  adult  life  and  are  thus 
able  to  inform  the  doctor  of  the  hidden  danger.  One  character- 
istic of  the  disease  is  seen  in  a  liability  to  bleed  from  the  slightest 
breaking  of  the  surface,  as  in  biting  the  tongue  or  scratching  the 
gums.  The  blood  leaks  forth  incessantl}',  and  no  more  effort  to 
stay  its  flow  appears  to  be  made  either  by  contraction  of  the  blood- 
vessels, or  by  clotting  of  the  blood,  than  if  the  stream  were  water, 
flowing  through  a  piece  of  inelastic  tube. 

In  a  remarkable  case  reported  by  the  late  Dr.  John  A.  Swett 
of  New  York,  this  disease  existed  in  all  the  children  of  a  family, 
eighteen  in  number.  All  except  one  had  died  in  consequence  of 
it,  and  this  one  was  then  suffering  from  profuse  hemorrhages  from 
the  nose  and  rectum. 

A  still  more  remarkable  case  is  described  by  Dr.  Hughes  of 
Kentucky.  The  predisposition  here  was  associated  with  a  rheu- 
matic diathesis,  and  was  satisfactorily  traced  back  as  far  as  five 
generations.  It  was  confined  exclusively  to  the  male  branches 
of  the  different  families,  but  the  females  invariably  transmitted  it  to 
their  offspring.  Many  of  the  individuals  died  from  the  cut  of  the 
lancet,  and  two  simply  from  the  application  of  blisters,  the  vesicles 
being  filled  with  blood  instead  of  water. 

Of  the  remote  cause  or  causes  of  this  disease  nothing  is  known. 
The  immediate  causes  may  be  indicated  under  two  heads  as  fol- 
lows: 


HEMORRHAGE.  57 

I  St.  A  want  of  coagulability  in  the  blood. 

2d.  An  imperfectly  organized  state  of  the  capillary  vessels. 

Treatment. — The  treatment  of  hemorrhage  involves  at  least  two 
propositions.  The  first,  prophylactic,  calls  for  treatment  with  the 
view  of  preventing  an  attack  of  bleeding;  the  second  considers  the 
means  of  arresting  existing  hemorrhage. 

The  two  leading  indications  are  to  promote  coagulability  of  the 
blood,  and  to  increase  the  contractility  of  the  capillary  vessels. 

The  acetate  of  lead  is  useful  as  an  agent,  internally,  to  assist  in 
the  coagulating  of  the  blood,  while  opium  affords  important  aid  in 
controlling  the  action  of  the  heart  in  addition  to  its  effect  upon  the 
blood.  The  acetate  of  lead  may  also  have  some  effect  upon  the 
contractility  of  the  capillary  vessels,  but  in  the  fulfillment  of  this 
object  ergot  is  far  more  powerful,  acting  on  the  non-striated  con- 
tractile fibers  of  the  minor  arteries.  It  should  be  administered  in 
the  form  of  the  fluid  extract,  twenty  to  thirty  drops  in  water,  re- 
peated according  to  the  exigencies  of  the  case. 

Nearly  all  the  cases  of  serious  hemorrhage  with  which  the  den- 
tist has  to  deal  are  those  resulting  from  the  extraction  of  teeth,  but 
it  is  to  be  remembered  that  much  may  often  be  accomplished  in 
the  way  of  preventive  treatment,  which  should  be  instituted  when- 
ever a  knowledge  of  the  previous  history  or  of  the  present  con- 
dition indicates  the  existence  of  a  hemorrhagic  diathesis.  Pre- 
ventive treatment  must  consist  in  the  removal  of  the  causes  which 
have  led  to  the  existing  diathesis,  and  prompt  hygienic  means 
should  be  used  to  restore  the  system  to  a  normal  condition.  The 
writer  has  had  success  in  the  use  of  small  doses  of  fluid  extract  of 
ergot,  fifteen  drops  in  water  three  times  daily  for  two  weeks  pre- 
vious to  the  operation. 

Treatment  for  hemorrhage  following  the  extraction  of  a  tooth 
must  vary  according  to  the  circumstances.  For  instance,  the 
patient  is  weak  and  anemic,  and  can  ill  afford  to  lose  a  large 
amount  of  blood.  The  hemorrhage  following  the  removal  of  the 
tooth  is  alarming;  the  blood  flows  ,into  the  mouth  with  great 
rapidity  and  with  considerable  force.  The  patient  is  excited,  the 
carotids  may  be  seen  throbbing  at  the  neck,  and  the  heart  may  be 
felt  thumping  against  the  chest  wall.  Now  in  such  a  case,  ex- 
cluding hemorrhagic  diathesis,  if  proper  treatment  is  promptly 
rendered  the  hemorrhage  may  be  arrested  within  a  short  time.  It 
is  important  at  once  to  allay  the  fears  of  the  patient,  to  maintain 


58  THE    PRACTICE    OF    DENTAL    MEDICINE. 

the  Upright  position,  and  to  apply  pressure  with  the  finger  over  a 
pledget  of  cotton  firmly  placed  in  the  alveolus.  Meanwhile  the 
face  may  be  bathed  with  cold  water,  or  an  ice-bag  placed  on  the 
head,  and  some  sedative  may  be  prepared  and  administered.  This 
may  be  the  tincture  of  opium,  or  sodium  bromid.  If  it  is  probable 
that  hemorrhage  may  occur  after  the  patient  has  left  the  office, 
the  fluid  extract  of  ergot  is  the  best  remedy. 

A  more  serious  hemorrhage  is  something  like  the  following: 
A  patient  presents  himself  with  a  persistent  bleeding  which  oc- 
curred several  hours  after  an  operation,  and  it  resists  the  ordinary 
treatment.  The  face  is  pale  and  haggard,  the  lips  are  stained,  the 
tongue  is  blackened  by  the  use  of  styptics,  and  the  teeth  are  cov- 
ered with  stringy  clots  of  blood.  The  first  and  most  important 
thing  to  do  is  thoroughly  to  clean  out  the  clotted  blood  from  the 
socket  of  the  tooth.  The  imperfect  removal  of  the  clot  is  probably 
one  of  the  most  common  obstacles  to  the  successful  treatment  of 
hemorrhage.  It  is  easily  seen  that  the  clotted  blood  must  prevent 
the  action  of  any  styptic  remedy,  as  well  as  pressure  at  the  bleed- 
ing-point. After  the  removal  of  the  clot  the  most  effective  local 
treatment  consists  in  the  combined  use  of  a  styptic  with  pressure, 
and  this  should  be  maintained  until  bleeding  has  ceased.  A  paste 
may  be  made  of  tannic  acid  and  glycerin,  which  should  be  carried 
to  the  bottom  of  the  alveolus  by  means  of  a  small  pledget  of  cotton. 
The  first  pieces  which  are  introduced  should  be  small,  in  order 
that  they  may  be  carried  entirely  to  the  bottom  of  the  socket;  these 
may  be  followed  by  larger  pieces  until  the  cavity  is  thoroughly 
plugged.  Various  means  are  used  to  obtain  pressure  upon  this 
plug,  but  if  the  case  be  an  urgent  one  the  finger  is  best  until 
danger  seems  to  be  over.  A  compress  may  be  placed  over  the 
plug  in  the  alveolus,  and  the  jaws  bound  together  by  a  bandage 
placed  over  the  top  of  the  head  and  beneath  the  chin. 

In  case  of  hemorrhage  coming  from  the  sockets  of  several  teeth 
or  from  an  entire  denture,  after  removing  all  clots  an  impression 
may  be  taken  in  wax,  gutta-percha,  or  modelling  composition,  and 
maintained  in  position  until  on  its  removal  bleeding  is  found  to 
have  ceased. 

It  has  often  been  the  case,  in  the  author's  experience,  that  the 
hemorrhage  does  not  come  from  all  the  tooth-sockets  alike,  and  it 
has  been  his  custom  to  find  the  most  active  bleeding-points  and 
treat  them  with  styptics  and  pressure  as  above  described.     Success 


HEMORRHAGE.  59 

depends  upon  the  thoroughness  with  which  the  first  piece  of  cotton 
is  driven  to  its  place. 

If  there  is  to  be  a  choice  between  Monsel's  powder,  or  solution, 
and  tannin,  the  choice  should  be  final;  in  other  words,  do  not  use 
tannin  and  Monsel's  solution  of  iron  in  the  same  case,  as  the  ink 
thus  formed  by  chemical  reaction  has  no  beneficial  efifect,  and  it  is 
sure  to  get  on  surrounding  tissues,  staining  them  and  making  an 
unsightly  appearance. 

The  chlorid  of  ethyl  spray  has  been  used  to  check  alveolar 
hemorrhage,  and  while  this  has  been  reported  as  successful,  the 
author  would  avoid  it  if  possible,  on  account  of  its  injurious  efifect 
upon  the  tissues,  preventing  the  proper  healing  of  the  wound. 

The  galvano-cautery  may  be  applied,  with  a  proper  electrode, 
directly  to  the  bottom  of  the  socket.  It  is  a  very  effective  agent  in 
controlling  hemorrhage,  besides  having  the  advantage  of  acting 
only  at  the  point  to  which  it  is  applied.  There  is  this  disadvantage, 
that  the  flowing  blood  may  prevent  thorough  cauterization  of  the 
parts.  The  electrolytic  needle  may  be  applied  in  the  same  way,  but 
it  causes  considerable  pain,  so  that  if  there  is  a  choice  the  prefer- 
ence should  be  given  to  the  cautery. 

Another  effective  means  of  checking  hemorrhage,  especially 
that  from  bone,  consists  in  the  use  of  Horsley's  antiseptic  wax. 
Prof.  W.  W.  Keen  of  Philadelphia  introduced  its  use  into  the  Jef- 
ferson College  Hospital.  This  preparation  consists  of  beeswax, 
seven  parts;  almond  oil,  one  part;  salicylic  acid,  one  part.  A 
small  quantity  of  this  wax  may  be  pressed  against  a  bleeding  bone 
or  surface,  or  introduced  into  the  bottom  of  the  alveolus.  This 
preparation  would  be  especially  indicated  in  the  hemorrhage  com- 
ing from  cancellous  bone  or  following  the  removal  of  an  epulis  or 
an  exostosis. 

Alum,  phenol  sodique,  tinctures  of  catechu,  kino,  and  myrrh 
may  be  used  in  cases  of  emergency,  when  more  powerful  styptics 
are  not  available. 

The  writer  recalls  a  remarkable  case  which  occurred  on  board 
ship,  of  a  persistent  and  very  serious  hemorrhage,  in  which,  in  the 
absence  of  a  better  remedy,  the  sole  of  a  boot  was  scraped  and  the 
substance  thus  obtained  was  packed  into  the  alveolus.  It  was 
effectual  in  controlling  the  bleeding;  thus,  as  it  was  said,  "a.  sole 
was  used  to  save  a  soul." 

The  constitmtional  ircatrncnt  is  important,  because  such  treatment 


6o  THE    PRACTICE    OF    DENTAL    MEDICINE. 

seeks  to  remove  the  underlying  and  predisposing  causes  of  the 
hemorrhage.  These  may  be  classed  under  three  heads:  first,  the 
imperfect  condition  of  the  blood  itself;  second,  a  relaxed  state  of 
the  capillaries;  third,  the  excessive  force  with  which  the  blood  is 
propelled  through  the  vessels  (blood-pressure). 

The  constitutional  treatment  should  be  directed  with  all  three 
of  these  conditions  in  view.  The  first  condition  is  one  which  is 
imperfectly  understood  as  to  etiology,  but  the  object  of  its  treat- 
ment is  plain,  that  of  promoting  the  coagulability  of  the  blood. 
For  this  purpose  there  are  two  remedies  which  are  much  used, 
gallic  acid  and  acetate  of  lead. 

^ — Acidi  gallici,  3j ; 

Aquas  cinnamomi,  oiij.     M. 

Sig. — Three  or  four  teaspoonfuls  every  hour. 

The  acetate  of  lead  may  be  administered  in  two-  to  five-grain 
doses  in  water,  every  three  hours.  It  is  an  old  and  tried  remedy. 
Abundant  clinical  experience  supports  its  use  and  it  undoubtedly 
has  an  effect  on  remote  parts.  Besides  promoting  the  coagula- 
bility of  the  blood,  it  slows  the  heart  and  constricts  the  vessels. 

To  contract  the  capillaries,  the  author  has  used  ergot  of  rye 
extensively,  both  as  a  hemostatic  and  as  a  prophylactic  remedy. 
It  may  be  administered  in  doses  of  twenty  to  thirty  drops  of  the 
fluid  extract  in  water. 

In  the  administration  of  ergot  much  depends  upon  the  urgency 
of  the  case.  In  severe  and  alarming  cases  it  has  been  given  in  tea- 
spoonful  doses.  The  writer  would  suggest,  in  an  ordinary  case  of 
profuse  hemorrhage,  the  administration  of  twenty  to  thirty  drops 
in  water  every  half-hour,  till  three  doses  have  been  taken. 

As  a  prophylactic,  fifteen  to  twenty  drops  in  water  should  be 
taken  three  times  daily  for  a  week  previous  to  operating. 

In  the  third  condition,  the  control  of  the  heart's  action  is  often 
overlooked.  This  should  never  be  the  case;  it  is  inconsistent  and 
unreasonable  to  go  on  applying  local  remedies  while  the  heart  is 
allowed  to  run  wild,  forcing  the  blood  out  through  the  wounded 
vessels,  often  in  spite  of  pressure  and  local  styptics;  for  it  may  be 
more  important  to  lessen  the  heart's  action  than  to  plug  the 
alveolus  in  a  case  of  alveolar  hemorrhage.  The  plugging  ought 
to  be  done;  the  other  should  not  be  left  undone. 

For  the  purpose  of  controlling  the  heart,  there  is  no  remedy 
equal  to  opium.     It  may  be  administered  in  any  form,  although  the 


COXSTIPATIOX.  6l 

crude  opium  has  been  suggested  as  having  better  effect.  The 
author  has  used  the  ordinary  tincture,  often  in  connection  with 
acetate  of  lead.  These  two  remedies  taken  during  the  same  time, 
but  in  separate  doses,  constitute  one  of  the  most  powerful  systemic 
hemostatics  known. 

The  position  of  the  body  should  be  such  as  to  elevate  the  bleed- 
ing part.  If  the  patient  is  in  bed,  have  the  shoulders  well  bolstered 
up. 

Ice  may  be  held  in  the  mouth,  or  the  opposite  extreme  may  be 
followed,  viz.  the  application  of  hot  water  by  means  of  a  syringe. 


CHAPTER    IX. 

CONSTIPATION. 


Synonyms. — Fecal  retention;  Costiveness. 

Relation  to  the  Treatment  of  Dental  Diseases. — The  consti- 
pated condition  is  one  of  obstruction  to  a  greater  or  less  extent, 
and  this  means  an  accumulation  of  effete  material  throughout  the 
system,  not  only  in  the  intestinal  canal  but  in  the  blood.  Such  a 
condition  favors  local  congestions  both  on  account  of  the  general 
obstruction  and  the  poisonous  matters  which  have  been  absorbed. 

In  view  of  these  premises  it  will  be  seen  how  important  it  is  to 
remove  this  condition  in  order  to  treat  successfull)'  any  infiamma- 
tion  of  the  mouth  or  structures  involving  the  teeth.  It  is  a  matter 
of  daily  observation  to  note  the  headaches  which  are  the  result  of 
constipation  alone,  and  if  headaches,  why  not  neuralgia  when  there 
is  a  sufficient  irritant  in  or  about  some  tooth? 

What  folly  it  is  to  treat  an  incipient  acute  alveolar  abscess  with 
anodynes  alone,  while  this  underlying  cause  of  the  tiouble  is  still 
present!  This  is  equally  true  of  all  inflammations,  such  as  pulpitis, 
pericementitis,  gingivitis,  stomatitis,  etc. 

Treatment. — The  treatment  of  constipation  will  be  given  only 
in  a  general  way  and  briefly,  as  follows:  Sufficient  exercise,  in  the 
open  air  if  possible;  special  exercise  designed  to  give  strength  to 
the  abdominal  muscles;  suitable  baths,  such  as  a  hot  bath  followed 


62  THE    PRACTICE    OF    DENTAL    MEDICINE. 

by  a  cold  douche,  if  the  patient  is  able  to  react  from  it.  Massage, 
or  kneading  the  bowels,  is  often  of  service;  regularity  at  stool 
should  be  maintained. 

A  large  amount  of  water  should  be  taken  before  breakfast  and 
during  the  day,  beginning  with  one  or  two  glasses  and  increasing 
to  six  or  eight.  It  can  usually  be  taken  if  the  patient  will  drink  a 
little  at  a  time,  waiting  a  few  minutes  between  draughts. 

A  most  beneficial  treatment  is  the  injection  of  one-half  to  one 
gallon  of  warm  water  into  the  bowel,  holding  it  for  some  minutes. 
It  thoroughly  removes  all  fecal  matter,  irrigates  the  bowel,  and 
washes  any  pockets  which  may  have  been  made  by  constipation  of 
long  standing. 

The  patient  should  adopt  a  diet  which  avoids  sweets  and  much 
meat,  and  consists  largely  of  vegetables  and  fruit.  Calomel  may 
be  used  in  acute  cases,  one-tenth  grain  every  hour  for  from  three 
to  five  houis,  and  if  there  is  no  effect  before  the  next  morning  a 
dose  of  magnesium  sulfate  in  a  glass  of  water  may  be  taken 
before  breakfast. 

In  cases  of  long  standing,  cascara  sagrada  is  an  efficient  remedy 
which  may  be  continued  for  months,  while  calomel  should  be  given 
only  in  temporary  cases  for  a  day  or  two. 


CHAPTER    X. 

SWALLOWING  PLATES  AND  OTHER  FOREIGN  BODIES. 

The  number  and  variety  of  foreign  bodies  which  have  been 
purposely  and  accidentally  swallowed  is  enormous,  and  the  list  of 
swallowers  includes  all  ages  and  conditions  of  human  beings,  from 
the  child  a  few  months  old  to  the  professional  sword-swallowers 
and  others  who  have  exhibited  from  time  to  time  in  various  parts  of 
the  world. 

As  examples  of  the  many  articles  which  have  been  swallowed, 
may  be  mentioned  knives,  pebbles,  broken  glass,  living  mice,  fish, 
insects,  nails,  watches,  pipes,  spoons,  and,  what  is  of  especial  im- 
portance to  the  dentist,  plates  containing  artificial  teeth. 


SWALLOWING    PLATES    AND    OTHER    FOREIGN    BODIES.  63 

Easton  mentions  the  case  of  a  young  man  who  accidentally 
swallowed  a  partial  gold  plate  with  teeth  attached.  He  had  taken 
castor  oil  when  seen  the  following  day,  and  was  suffering  con- 
siderable pain  in  the  stomach.  He  was  advised  to  eat  heartily  of 
food  and  to  avoid  aperients.  On  the  following  day,  after  several 
free  movements,  he  felt  a  sharp  pain  in  the  lower  part  of  his  back. 
A  large  enema  was  given  and  the  plate  came  away.  This  plate 
did  service  for  nine  years  more,  when  it  was  again  swallowed,  but 
this  time  nothing  was  seen  of  it  for  a  month  afterward,  when  it 
was  unexpectedly  discharged  from  the  anus. 

In  the  Lancet  for  Dec.  lo,  1881,  there  is  an  account  of  the 
swallowing  of  a  vulcanite  plate  which  was  passed  forty-two  hours 
afterward.  Gardner  relates  the  case  of  a  woman  of  thirty-three 
years  who  swallowed  a  plate  containing  two  teeth;  a  sharp  angle 
of  the  plate  caught  in  a  fold  of  the  stomach,  causing  profuse 
hemorrhage  and  ultimate  death. 

In  1886,  Dr.  M.  H.  Richardson  of  Boston*  performed  gastrot- 
omy  for  the  removal  of  a  plate  with  teeth,  it  being  the  first  case 
on  record  in  which  the  hand  was  introduced  into  the  stomach  for 
the  purpose  of  removing  a  foreign  body.  The  plate  in  this  case 
was  located  in  the  esophagus  about  two  inches  from  the  cardiac 
opening  into  the  stomach.  The  patient  was  a  teamster,  aged 
thirty-seven,  and  the  plate  had  been  in  the  esophagus  eleven 
months.  There  was  constant  pain,  great  emaciation,  and  inability 
to  swallow  food.  Recovery  followed  the  operation  and  the  man 
went  back  to  work  in  eleven  weeks. 

The  following  case  was  reported  to  the  Massachusetts  Dental 
Society  by  Dr.  Elbridge  C.  Leach  of  Boston,  to  whose  courtesy 
the  writer  is  indebted  for  the  facts  here  given:  The  patient, 
G.  W.  S.,  aged  forty,  was  awakened  early  on  the  morning  of 
November  9,  1884,  by  an  uncomfortable  feeling  in  his  throat.  On 
inspection  his  wife  could  see  his  partial  upper  denture  in  the  fauces, 
and  could  touch  it  with  her  finger  but  was  unable  to  remove  it. 
The  family  physician  was  called,  who  was  likewise  unable  to 
remove  the  plate,  which  had  then  disappeared  from  sight.  A 
special  train  took  the  patient  to  Boston,  where,  at  the  Massa- 
chusetts General  Hospital,  another  attempt  was  made  to  remove 
the  plate,  without  success.  Finally,  it  was  pressed  down  into  the 
stomach  and  the  patient  allowed  to  go  home.     For  ten  days  the 

*  Boston  Medical  and  Surgical  Journal,  1S86,  vol.  ii.  p.  569. 


64 


THE    PRACTICE    OF    DENTAL    MEDICINE. 


patient  suffered  from  the  manipulations  in  his  throat,  after  which 
time,  he  went  about  his  duties  as  conductor  on  the  New  York  and 
New  England  Railroad.  He  continued  thus  wathout  an  unusual 
symptom,  until  February  22,  1885,  when  he  had  difficulty  in  defeca- 
tion, having  some  pain  and  feeling  a  hard  lump  in  the  rectum. 
After  manipulation  a  mass  was  removed  in  which  the  plate  was 
found,  quite  firmly  imbedded.  Fig.  7  is  an  exact  reproduction  of 
the  denture,  the  longest  diameter  of  which  was  two  inches,  the 
shortest  diameter  being  one  inch  and  three-eighths. 

An  interesting  Case,  as  to  the  number  and  character  of  foreign 
bodies  swallowed,  the  successful  performance  of  gastrotomy,  and 
the  first  use  of  the  Roentgen  rays  for  the  location  of  foreign  bodies 


Fig.  7. 


^-    1*    _  -^ 


in  the  stomach,  is  as  follows:*  The  patient,  "Signor  Ranana," 
aged  twenty-two,  was  a  professional  "swallower"  and  termed  him- 
self the  "human  ostrich."  Gastrotomy  was  performed  by  A.  H. 
Meisenbach,  M.D.,  April  7,  1897,  at  the  Rebekah  Hospital,  St. 
Louis,  Mo.  One  hundred  and  twenty-seven  objects,  including 
staples  for  barbed  fence-wire,  two-inch  nails,  pocket-knife  blades, 
cartridges,  glass,  etc.,  were  removed, — in  all,  one  pound.  The 
patient  made  a  good  recovery. 

Gooch  quotes  the  case  of  a  man  who  swallowed  a  knife,  which 
was  voided  at  the  groin  nine  months  afterward.  Laurentius  Jou- 
bert,  in  the  sixteenth  century,  tells  of  a  case  in  which  a  knife  was 
swallowed,  remaining  in  the  body  two  years.  In  1691  a  country 
lad  of  Saxony,  w-hile  playing  tricks  with  a  knife  six  and  one-half 
inches  long,  swallowed  it,  point  first.  It  was  successfully  extracted 
from  the  stomach,  where  it  had  been  two  years  and  seven  months. 

*  The  first  case  on  record  in  which  pneumonia  followed  the  use  of  the 
X  rays. 


SWALLOWING    PLATES    AND    OTHER    FOREIGN    BODIES.  65 

Chopart*  relates  the  case  of  a  ravenous  galley-slave,  who  died  in 
1774,  and  in  whose  stomach  were  found  fifty-two  foreign  bodies, 
including  a  barrel-hoop  nineteen  inches  long,  nails,  pieces  of  pipe, 
buckles,  spoons,  glass,  seeds,  and  a  knife. 

Velpeau  mentions  a  case  in  which  a  fork  was  passed  from  the 
anus  twenty  months  after  it  was  swallowed.  In  the  Royal  College 
of  Surgeons  of  London  there  is  a  steel  button-hook  three  and  one- 
half  inches  long,  which  had  been  accidentally  swallowed  and  was 
passed  three  weeks  later  without  unfavorable  symptoms. 

While  in  many  cases  large  and  irregular  bodies  have  been 
swallowed,  and  have  passed  through  the  alimentary  canal  without 
serious  illness  or  loss  of  life,  it  should  nevertheless  be  understood 

Fig.  8. 


Tooth-plate,  actual  size. 

that  there  is  always  great  risk;  and  especially  is  this  the  case  when 
the  foreign  body  lodges  in  the  esophagus,  and  cannot  be  moved 
either  upward  or  downward.  When  this  condition  exists,  esopha- 
gotomy  should  at  once  be  performed;  delay  is  fatal. 

Of  the  one  hundred  and  sixty-nine  reported  cases  of  esopha- 
gotomy  for  the  removal  of  foreign  bodies,  fifty-one  were  for  the 
removal  of  plates  with  artificial  teeth;  with  thirty-six  recoveries 
and  fifteen  deaths. 

The  following  cases  are  examples  which  give  emphasis  to  these 
remarks:  The  first  case  was  one  in  which  Dr.  John  O.  Roe,  of 
Rochester,  N.  Y.,  performed  esophagotomyf  for  the  removal  of  a 
partial  denture.  (Fig.  8.)  The  patient  had  swallowed  the  plate 
five  days  previous  to  the  operation,  consequently  that  portion  of 
the  esophagus  surrounding  the  foreign  body  was  much  inflamed. 

*  Quarterly  Joitrnal  of  the  Calcutta  Medical  and  Physical  Society,  1837, 
i.  291. 

't  Journal  of  the  American  Aledical  Association,  March  26,  1898. 

6 


66  THE    PRACTICE    OF    DENTAL    MEDICINE. 

The  operation  was  performed  without  accident,  the  plate  removed, 
and  for  four  days  the  patient  seemed  to  be  making  a  good  re- 
covery; but  on  the  fifth,  a  chill,  succeeded  by  a  rising  temperature 
and  inflammation  of  the  lungs,  was  followed  by  death.  In  another 
case  of  esophagotomy,  performed  by  Wilson*  for  the  removal  of  a 
partial  denture,  the  operation,  performed  for  a  patient  aged  sixty- 
five,  was  followed  by  death. 

Treatment. — The  dentist  should  caution  his  patients  in  regard 
to  wearing  partial  dentures  at  night,  and  not  to  neglect  having 
plates  repaired  when  necessary,  for  it  is  interesting  to  note  that  in 
the  above  case  the  plate  originally  had  clasps  which  held  it  in  posi- 
tion, but  these  having  been  broken  off  had  not  been  replaced,  the 
result  eventually  being  loss  of  life. 

When  a  foreign  body  is  swallowed  it  is  sometimes  arrested  in 
its  course  near  the  fauces,  or  within  reach  of  instruments  by  which 
it  may  be  extracted  through  the  mouth.  In  other  cases  it  may 
pass  into  the  trachea,  often  necessitating  tracheotomy;  and  in  still 
other  cases  it  may  pa.ss  into  the  esophagus,  and  become  fixed  at 
any  point  where  it  happens  to  lodge,  in  which  case  an  operation  for 
its  removal  should  not  be  delayed.  In  fact,  there  is  a  possibility 
of  irregular  or  sharp-pointed  bodies  becoming  imbedded  in  the 
tissues  at  any  point  in  the  alim.entary  canal.  If  the  body  swal- 
lowed passes  into  the  stomach,  it  is  popularly  supposed  that  the 
patient  should  abstain  from  food,  but  this  idea  is  unscientific. 
The  proper  treatment  in  such  a  case  is  to  feed  the  person  upon 
large  quantities  of  boiled  rice,  or  other  similar  material;  the  object 
being  to  distend  not  only  the  stomach,  but  the  entire  intestinal 
tract.  This  distension  opens  the  folds  of  tissue  and  thus  pre- 
vents the  foreign  body  from  lodging  in  them;  it  also  serves  to 
carry  along  the  substance,  as  well  as  to  detach  it  from  any  places 
where  it  may  have  become  fixed.  This  treatment  should  be  per- 
sisted in  for  a  long  time,  if  necessary. 

If  the  X  ray  or  other  conclusive  evidence  shows  that  the  for- 
eign body  is  in  the  stomach  and  persists  in  remaining  there,  it  may 
be  deemed  expedient  or  even  necessary  to  attempt  the  removal  of 
the  foreign  substance  by  means  of  a  surgical  operation,  such  as 
gastrotomy. 

*  Liverpool  Medical  Journal,  July  1894,  p.  480. 


STOMATITIS. 


67 


GENERAL   DISEASES    HAVING   LOCAL    EXPRESSION 
IN    THE    MOUTH. 


CHAPTER    XI. 

STOMATITIS. 

The  following  classification  of  diseases  affecting  the  mucous 
membrane  of  the  mouth  has  been  adopted  by  the  American  Pedi- 
atric Society : 

simplex. 

exanthematica    (secondary  to  the  exanthemata). 

{Mechanical. 
traumatica.-^  Thermal. 
[^Chemical. 

herpetica  (aphthosa). 

{Scorbutus.  ,  . 

Arsenic. 
Mineral  poisons,  also  other  diseases.]  j^g^fj 

fhyphomycetica  (Thrush).     [Mercury. 

Diphtheria. 


Stomatitis 


'catarrhalis  - 


ulcerosa. 


mycetogenetica' 


pseudo-membranosa  - 
^gangrsenosa  (Noma). 


Tuberculosis. 
Syphilis  and  like 
diseases. 


CATARRHAL  STOMATITIS. 

Synonyms. — Simple  stomatitis;  Common  diffuse  inflammation 
of  the  mouth. 

Etiology. — ^Catarrhal  stomatitis  is  a  mild  disease  not  easily 
recognized,  and  which  under  proper  treatment  lasts  only  a  few 
days;  yet  this  slight  affection,  if  allowed  to  go  unrestricted,  may 
lead  to  ulceration. 

It  is  most  frequently  observed  in  infants  between  two  months 
and  one  year  old;  and  more  particularly  among  the  poor,  for  rea- 
sons which  will  be  shown. 

The  various  causes  of  this  disease  may  be  summed  up  in  one 
sentence,  viz.  some  irritant  to  the  mucous  membrane.     The  various 


68  THE    PRACTICE    OF    DENTAL   MEDICINE. 

irritating  agents  may  be  mechanical,  thermal,  or  chemical,  or  the 
disease  may  be  due  to  micro-organisms. 

While  the  eruption  of  the  teeth  may  be  attended  with  increased 
vascularity,  it  is  not  in  itself  sufficient  to  produce  a  general  catar- 
rhal stomatitis-  Lack  of  cleanliness  is  a  commonly  accepted  cause 
that  is  always  evident  upon  inspection.  A  dyspeptic  condition 
always  predisposes  one  to  stomatitis,  the  oral  mucous  membrane 
participating  in  the  general  irritable  condition,  being  directly  acted 
upon  by  the  acid  secretions  which  accompany  the  digestive  dis- 
turbance. 

At  the  present  time  it  has  not  been  shown  that  any  forms  of 
bacteria  are  causative.  It  is  true,  however,  that  any  abnormal 
condition  of  the  mucous  membrane  must,  in  proportion  to  the 
degree  of  depaiture  from  health,  furnish  conditions  under  which 
the  lower  forms  of  life  would  thrive.  A  scrofulous  diathesis,  or 
the  results  of  some  former  disease,  may  act  as  predisposing  causes 
of  stomatitis. 

Other  causes,  acting  directly,  are  a  fractured  tooth  with  sharp 
edges,  an  alveolar  abscess  opening  into  the  mouth,  the  excessive 
use  of  confectionery,  or  the  wearing  of  regulating  appliances  which 
are  not  properly  cleansed. 

Pathology. — The  parts  involved  in  the  catarrhal  form  of  stoma- 
titis are- all  those  which  make  up  the  oral  cavity,  viz.  the  tongue, 
the  cheeks,  the  mucous  membrane  covering  the  jaws,  the  inner 
surface  of  the  lips,  the  soft  and  the  hard  palate. 

In  the  early  stages  the  membrane  presents  an  erythematous 
appearance;  later,  the  true  catarrhal.  At  first  there  is  simply  an 
overfilling  of  the  bloodvessels;  in  other  words,  hyperemia  of  the 
mucous  membrane.* 

The  secretions  of  the  mouth  are  often  suppressed  at  first,  but 
after  the  pathological  condition  is  fully  established  they  are  in- 
creased. The  mucous  membrane  lining  the  cheeks  is  often  marked 
by  the  teeth,  as  shown  by  slight  depressions.  The  color  of  this 
membrane,  especially  in  the  little  depressions  made  by  the  teeth,  is 
paler  than  in  the  other  parts  of  the  mouth,  while  the  corresponding 
elevations  surrounding  the  depressions  are  marked  by  increased 
vascularity;  the  vessels  bemg  dilated  and  thus  weakened  so  that 
the  slightest  injury  causes  more  or  less  bleeding.     The  lips  are 

*  In  the  newly  born,  however,  it  should  be  remembered,  a  hypereniic 
condition  normally  exists  during  the  first  week  of  life. 


CATARRHAL    STOMATITIS.  69 

swollen  and  tense,  the  mucous  membrane  is  reddened,  and  the 
surface  shows  small  round  prominences  caused  by  the  accumula- 
tion of  secretion  in  the  muciparous  follicles  due  to  an  obstruction 
of  their  ducts.  Should  complete  occlusion  of  the  ducts  occur,  the 
glands  become  greatly  enlarged,  forming  cysts.  If  a  cyst  is  opened 
and  discharged  of  its  thickened  mucus,  it  is  likely  to  refill  re- 
peatedly unless  active  treatment  is  instituted. 

On  inspection,  the  tongue  is  seen  to  be  covered  with  a  dry, 
whitish  coating,  which  after  a  time  becomes  moist  and  is  removed 
in  patches  along  the  edges  and  toward  its  center.  Later  the  coat- 
ing changes  in  color  to  gray  or  yellow.  The  lymphatic  glands 
are  nearly  always  enlarged,  indicating  by  their  size  the  intensity 
of  the  disease. 

Symptoms, — The  local  symptoms  of  stomatitis  are  pain  and 
dryness,  followed  by  an  increased  flow  of  saliva.  The  mouth  is 
dry  and  hot  from  the  beginning  and  the  taste  becomes  perverted. 
An  infant  goes  to  the  breast  as  a  hungry  child  would,  but  soon  it 
lets  go  the  nipple  and  begins  to  cry.  This  is  repeated  until  the 
little  one  is  exhausted  and  finally  refuses  the  breast  altogether, 
preferring  hunger  to  pain.  The  flow  of  saliva  is  often  profuse, 
flowing  over  the  lips  and  chin,  irritating  the  skin  and  producing 
an  eczema  which  may  last  long  after  the  drooling  has  subsided. 

The  general  condition  of  the  patient  varies  to  a  considerable 
extent,  but  there  is  usually  at  night  some  fever,  the  temperature 
ranging  from  ioi°  to  102°  F.  In  some  cases  the  temperature  may 
go  as  high  as  104°  F. ;  this,  of  course,  demands  special  attention. 

Course,  Duration,  etc. — Catarrhal  stomatitis  usually  lasts  but  a 
few  days  if  properly  treated.  It  may  run  into  a  chronic  form,  and 
into  ulceration,  if  left  to  itself,  but  even  then  it  is  amenable  to  treat- 
ment, x 

Prognosis." — ^Catarrhal  stomatitis  responds  readily  to  treatment, 
but  if  neglected  serious  results  may  follow.  For  instance,  if  the 
child  is  prevented  from  taking  food  because  of  the  pain  induced 
thereby,  the  system  will  be  weakened  to  such  an  extent  as  to  make 
recovery  doubtful. 

Diagnosis. — The  prominent  signs  by  which  this  form  of  stoma- 
titis is  distinguished  from  the  others  are  the  marked  redness  of  the 
mucous  membrane,  the  absence  of  white  patches  or  vesicles  (al- 
though superficial  ulceration  may  occur  at  different  points),  and 
the  temporary  character  of  the  disease,  which  ^asts  but  a  few  days. 


70  THE    PRACTICE    OF    DENTAL   MEDICINE. 

If  it  does  last  longer,  it  is  then  that  ulceration  occurs.  The  ulcera- 
tion may  be  distinguished  from  syphilitic  mucous  patches  by  the 
history,  form,  and  duration  of  the  patches.  The  syphilitic  ulcer  is 
not  so  sharply  defined,  and  contains  an  ash-gray  slough  closely 
attached;  it  is  sluggish  and  heals  with  difficulty,  appearing  and 
disappearing;  besides,  there  will  be  syphilitic  lesions  in  other  parts 
of  the  body  attended  by  characteristic  symptoms. 

Treatment. — Although  the  disease  usually  lasts  but  a  few  days, 
prophylactic  treatment  should  be  conscientiously  carried  out,  as 
the  possibility  always  remains  that  this  may  be  the  beginning  of 
more  serious  troubles.  Cleanliness  is  of  supreme  importance,  and 
mothers  should  be  taught  the  necessity  of  keeping  the  mouth  as 
well  as  the  skin  of  the  child  clean  at  all  times.  The  cleansing  pro- 
cess depends  somewhat  upon  the  age  and  condition  of  the  patient, 
for  an  infant  or  restless  child  will  not  always  allow  a  spray  or  the 
use  of  an  instiument;  in  such  cases  it  is  well  to  use  absorbent  cot- 
ton dipped  in  warm  water  and  wrapped  around  the  finger  as  an 
application.  The  nipples  cf  the  mother  or  nurse  may  be  a  source 
of  infection,*  and  if  artificial  feeding  be  practiced  the  nursing  bottle 
should  be  made  aseptic  by  washing  thoroughly  and  placing  it  in 
water  which  is  subsequently  heated  to  the  boiling-point;  the  nip- 
ple should  be  turned  inside  out  Lnd  thoroughly  scrubbed. 

The  quantity  and  quality  of  the  food  should  be  strictly  regu- 
lated, and  it  should  also  be  remembered  that  unduly  warm  articles 
of  food  cause  pain  as  well  as  irritation. 

Examine  the  teeth,  if  there  are  any,  to  see  if  there  are  sharp 
edges,  or  if  they  in  any  way  act  as  irritants,  either  mechanically  or 
chemically  on  account  cf  uncleanliness. 

The  food  should  usually  be  given  cold  if  the  child  is  artificially 
fed.  Lime-water  added  to  the  milk  is  often  of  great  benefit;  one 
part  of  lime-water  to  two  parts  of  milk. 

If  there  are  points  of  ulceration,  they  may  be. touched  with 
nitrate  of  silver  melted  on  the  point  of  a  silver  or  glass  probe,  or 
with  carbolic  acid  on  the  point  of  a  probe. 

To  allay  the  heat  of  the  mouth,  frequent  rinsing  with  cold 

*  The  nipples  should  be  bathed,  after  nursing,  with  the  following  solu- 
tion: 

^ — Sodii  boratis,  gr.  xxx; 

Glycerini,  3ij ; 

Aquse  destil.,  ad    §iv.         M. 


STOMATITIS    HERPETICA.  7^ 

water,  or  (for  infants)  a  piece  of  linen  dipped  in  ice-water  and 
inserted  into  the  month,  or  bits  of  ice  wrapped  in  linen  and  used  in 
the  same  way,  will  be  found  to  be  very  soothing.  Local  applica- 
tions and  mouth-washes  are  useful.  A  solution  of  silver  nitrate, 
one  grain  to  the  ounce  of  water,  may  be  applied  to  the  affected 
mucous  surfaces  with  a  camel's-hair  brush,  or  the  following  may 
be  used  in  the  same  way: 

IJ — Acid,  carbolici,  Calvert's  No.  i,      gtt.  xv; 

Ol.  gaultherize,  gtt.  ij ; 

Tinct.  cardamomi  comp.,  5ij ; 

Aquffi,  q.  s.  ad     oiv.         M. 

Sig. — Apply  to  the  mouth  with  a  camel's-hair  brush. 

Professor  Hare  of  Philadelphia  recommends  the  following: 

I^ — Potass,  chloratis,  gr.  xxx; 

Tinct.  myrrhas,  ^  xij ; 

Elixir  calisayse,  q.  s.  ad     floiij.         M. 
Sig. — Use  as  a  mouth-wash. 

STOMATITIS  HERPETICA. 

Synonyms. — Stomatitis  aphthosa;  Canker;  Aphthous  stomatitis. 

Definition.- — Spots  of  different  color  appearing  within  the 
mouth  and  situated  under  the  epithelium,  circumscribed  by  an 
areola  varying  in  color. 

Etiology. — Many  opinions  have  been  expressed  on  this  sub- 
ject, but  no  satisfactory  conclusion  as  to  the  cause  of  this  affection 
has  yet  been  reached.  No  lesions  have  been  found  which  can  be 
considered  conclusive  on  this  point.  Caustics  have  been  applied 
by  Gerhardt,  producing  lesions  in  the  mouth  similar  to  aphthae, 
but  aphthous  stomatitis  occurs  without  apparent  external  cause. 
The  agency  of  bacteria  in  the  etiology  is  not  supported  by  the 
latest  researches.  It  has  been  shown  by  Bohn  that  the  greatest 
number  of  cases  occur  between  the  first  and  third  years  of  age,  and 
it  may  be  something  more  than  a  coincidence  that  the  process  of 
teething  is  actively  going  on  during  this  time,  and  that  it  may  have 
something  to  do  in  producing  aphthae.  But  we  find  aphthous 
stomatitis  associated  with  pneumonia,  gastric  and  intestinal  dis- 
orders, ague,  etc.  It  has  been  suggested  that  this  disease  must 
originate  through  the  nervous  system,  and  some  interesting  theo- 
ries have  been  advanced,  but  we  are  still  in  the  dark  as  to  the  cause 
of  stomatitis  aphthosa. 

Pathology. — The  term  "aphthae"  was  formerly  applied  to  all 


72  THE    PRACTICE    OF    DENTAL    MEDICINE. 

inflammations  of  tlie  mucous  membrane  of  the  mouth,  but  it  is 
now,  or  should  be,  restiicted  to  the  spots  or  ulcerations  above  de- 
scribed. The  condition  presented  is  popularly  known  as  "canker." 
(See  Plate  I.) 

As  to  the  exact  nature  of  these  spots,  there  is  still  doubt  ex- 
pressed, some  believing  them  to  be  a  vesicular  eruption,  while 
others  declare  them  to  be  a  solid  exudation.  Bohn  and  others 
insist  that  they  have  never  seen  the  fluid  supposed  to  be  contained 
in  these  vesicles.  Many  authorities  use  the  terms  aphthous  and 
follicular  interchangeably;  Bellard  and  others  express  their  belief 
that  follicular  stomatitis  is  the  origin  of  all  aphthae. 

Follicular  inflammation  may  not  proceed  so  far  as  to  cause 
ulceration,  the  inflamed  follicles  contrasting  with  the  surrounding 
mucous  membrane.  This  form  of  inflammation  is  characterized 
by  small  round  spots,  red  and  slightly  elevated,  hard  to  the  touch, 
somewhat  like  shot  under  the  skin,  and,  if  the  inflammation  con- 
tinues, the  hard  spots  soften  in  the  center  and  ulceration  takes 
place.  The  origin  of  aphthae  is  also  said  sometimes  to  be  in  a 
vesicular  eruption  which  appears  not  only  in  the  follicles,  but  in 
an}^  part  of  the  mucous  membrane  of  the  mouth.  The  vesicles,  if 
seen  early,  are  filled  with  a  clear  fluid  which  in  time  becomes 
whitish;  around  which  is  seen  a  circle  of  inflammation.  After  the 
rupture  of  the  vesicle  a  small  ulcer  appears  with  a  grayish-yellow 
base,  the  margins  of  which  are  sharply  defined  and  of  bright  red 
color.     These  ulcers  are  usually  very  sensitive  and  painful. 

Aphthous  ulcerations  are  most  frequently  found  on  the  inner 
surface  of  the  lip  and  cheek,  in  the  sinus  between  the  cheek  and 
gums,  and  along  the  sides  of  the  tongue. 

We  have  spoken  of  aphthous  ulcers.  It  should  be  noted  that 
there  are  objections  made  to  such  a  use  of  this  term.  Bohn  ob- 
jects on  the  ground  that  it  is  exceedingly  rare  to  find  pus  in  any 
perceptible  quantity  in  what  is  called  an  aphthous  ulcer.  His 
objection  is  reasonable  on  the  ground  that  pus  is  an  essential 
element  in  the  formation  of  an  ulcer.  After  all,  it  is  best  to  bear 
in  mind  that  we  are  dealing  with  a  term  in  constant  and  frequent 
use,  and  that  while,  strictly  speaking,  in  aphthous  excavations,  the 
destruction  of  tissue  may  not  be  that  of  an  ulcer,  nevertheless  we 
are  practically  dealing  with  an  ulcer;  indeed,  constitutional  dis- 
turbances may  be  quite  as  severe  as  if  pus  were  being  formed. 
Fortunately,  however,  such  cases  even  in  children  are  very  rare. 


PLATE    I. 


STOMATITIS    HERPETICA.  73 

Symptoms. — A  preliminary  redness  of  the  mucous  membrane  of 
the  mouth  is  followed  suddenly  by  the  characteristic  aphthous 
spots,  which  develop  within  twenty-four  hours.  These  spots  of  a 
yellowish-white  color  may  appear  singly  or  in  groups,  and  may  be 
seen  in  any  part  of  the  mouth,  and  occasionally  over  the  surface  of 
the  pharynx.  Although  the  spots  may  be  associated  closely  to- 
gether in  many  cases,  it  is  rare  to  see  what  is  termed  confluent 
aphthae.  After  the  eruption,  as  first  presented,  has  existed  for 
twenty-four  hours,  it  loses  its  epithelial  covering,  and  there  is  left 
what  is  called  an  aphthous  ulcer.  This  is  formed  by  the  pre-exist- 
ing red  line,  within  which  is  the  depression  made  by  the  loss  of  the 
epithelial  layer. 

In  a  few  days  the  borders  of  the  ulcer  may  be  seen  to  approach 
the  center,  covering  the  depression  with  a  new  epithelial  layer; 
or  some  aphthae  may  be  absoibed  without  the  outer  epithelial  layer 
breaking.  There  may  also  be  complications  caused  by  these  de- 
nuded surfaces  becoming  infected,  in  which  case  a  suppurative 
process  is  established.  The  case  is  usually  prolonged  by  succes- 
sive crops  of  aphthae  for  from  ten  to  fourteen  days. 

Examinations  of  the  exudation,  up  to  the  present  time,  have 
shown  small  cell-fibers  and  low  forms  well  known  as  inhabitants  of 
the  mouth,  but  no  pathogenic  forms  which  could  be  said  to  cause 
the  eruption  above  described. 

The  constitutional  symptoms  vary  much  with  each  case;  often 
little  disturbance  ensues,  although  the  irritation  in  the  mouth 
always  causes  more  or  less  pain  or  restlessness,  salivation,  coated 
tongue,  and  loss  of  appetite. 

ProgTxOsis. — The  prognosis  is  favorable.  The  disease  is  self- 
limited  and  occasions  no  serious  injury  to  the  structures  which  it 
involves,  neither  is  it  dangerous  to  life,  with  the  rare  exception  of 
the  confluent  form  in  children,  in  which  the  constitutional  disturb- 
ance is  profound,  as  indicated  by  the  diarrhea  and  vomiting,  and 
the  spread  of  the  local  disease  to  other  parts  of  the  alimentary 
canal. 

Diagnosis. — In  distinguishing  aphthous  patches  from  diph- 
theria the  following  points  should  be  noticed:  In  diphtheria  the 
exudation  usually  begins  as  a  small  white  spot  or  pellicle  on  the 
soft  palate  or  tonsils.  The  aphthous  sores  occur  as  a  curd-like 
mass  on  the  lips,  gums,  or  cheeks,  extending  backward  to  the 
pharynx.     The   diphtheritic   spots   advance   toward  the   lips.     In 


74  THE    PRACTICE    OF    DENTAL    MEDICINE. 

diphtheria  the  exudation  widens  as  it  develops  and  extends  into 
the  posterior  nares  and  down  the  larynx;  with  aphthae  this  is 
not  the  case.  In  every  case  of  suspected  diphtheria  a  bit  of  the 
exudation  should  be  obtained  on  the  point  of  a  sterile  platinum 
probe  to  be  subjected  to  a  culture-test  by  one  who  is  expert  in  the 
process,  which  will  settle  the  diagnosis  beyond  a  doubt  so  far  as 
diphtheria  is  concerned. 

It  should  be  remembered  that  many  authorities  consider  aph- 
thous stomatitis  and  the  form  known  as  "thrush"  as  one  and  the 
same  disease.  The  points  of  difference  to  be  noted  are :  In 
aphthae  the  small  ulcers  show  when  the  white  crusts  are  removed; 
the  vesicular  nature  of  the  disease  in  its  first  stages;  the  grayish 
covering  of  the  ulcers,  which  is  soluble  in  ether  and  shows  many 
oil-globules  under  the  microscope;  while  in  "thrush"  there  is  a 
special  fungus,  of  the  mold  form,  although  of  what  precise  char- 
acter of  mold  has  not  yet  been  ascertained. 

Treatment. — A  course  of  medicine  is  little  needed  for  the  treat- 
ment of  stomatitis  proper,  although  it  may  be  necessary  in  treat- 
ing complications  or  depraved  states  of  the  system.  If  purgatives 
are  required,  a  small  dose  of  rhubarb  and  soda  may  be  given  to 
children.  Potassium  chlorate  alone,  also  in  conjunction  with  iron, 
is  often  given,  but  the  benefit  is  questionable.  Locally,  the  object 
is  to  lessen  the  pain  of  the  ulcers  and  prevent  infection,  both  these 
objects  being  accomplished  by  the  application  of  nitrate  of  silver  or 
carbolic  acid.  Demulcent  washes,  as  mucilage,  should  be  used 
until  the  inflammation  subsides,  when  astringents  may  bs  em- 
ployed, such  as  a  solution  of  alum,  acetate  of  lead,  or  sulfate  of  cop- 
per or  zinc,  applied  to  the  ulcers  with  a  camel's-hair  brush. 

STOMATITIS    HYPHOMYCETICA. 

Synonyms. — Stomatitis  pseudo-membranosa;  Thrush;  Soor; 
White  mouth,  or  Le  muguet  (Fr.);  Schwammchen  (Germ.); 
Stomatitis  cremosa. 

Etiology. — This  form  of  stomatitis  is  due  to  a  fungus  which 
finds  lodgment  in  the  mucous  membrane  of  the  mouth.  This 
growth  is  one  of  the  mold  fungi,  and  was  formerly  supposed  to  be 
the  Oidium  albicans,  but  it  is  now  known  that  it  is  not  this  organism 
which  produces  thrush,  although  the  precise  form  of  mold  has  not 
yet  been  determined.  Under  the  microscope  the  curdy  exudation 
has  been  found  to  consist  of  thickened  epithelium-cells  together 


STOMATITIS    HYPHOMYCETICA.  75 

with  sporules,  forming  clusters  from  the  midst  of  which  long, 
thread-like,  jointed  and  branching  plants  arise,  intertwining  with 
one  another.  The  sporules  which  are  floating  about  in  the  air,  on 
being  inhaled  attach  themselves  to  the  mucous  surface,  and  when 
favorable  conditions  exist  they  develop  and  propagate.  The 
growth  of  this  fungus,  as  well  as  that  of  other  microscopic  fungi, 
seems  to  be  greatly  favored  by  an  acid  condition  of  the  oral  secre- 
tions. Some  previously  defective  state  of  the  body  may  have 
wrought  the  change  from  the  normal  alkaline  fluid  to  one  of 
acidity,  and  thus  the  necessary  soil  is  furnished  by  which  the  fungus 
is  developed  and  the  diseased  condition  of  the  mouth  is  produced. 

It  is  known  that  this  fungus  is  very  widely  distributed,  being 
found  upon  every  mucous  membrane  in  the  body,  and  in  some 
instances  within  the  substance  of  the  brain  and  lungs.  It  is  gen- 
erally conceded  that  this  disease  is  found  most  commonly  in  in- 
fants during  the  first  two  or  three  weeks  of  life,  but  it  is  also  known 
to  occur  at  any  period  of  life.  It  is  commonly  observed  that  a 
catarrhal  stomatitis  may  accompany  the  parasitic  form,  often  pre- 
ceding it;  and  that  a  child  sufifering  with  any  form  of  stomatitis  is 
more  liable  to  thrush  by  reason  of  the  existence  of  the  other  form. 
It  has  been  demonstrated,  however,  that  some  form  of  irritation  to 
the  mucous  membrane,  a  break  in  the  continuity  or  a  rupture  of 
the  surface,  is  necessary  before  it  becomes  diphtheritic.  It  has 
been  observed,  especially  in  cases  of  infants,  that  when  there  has 
been  an  abrasion  of  the  mouth  from  any  cause,  thrush  has  immedi- 
ately followed  in  consequence,  but  this  does  not  take  away  the 
strong  probability  that  the  swollen  and  displaced  epithelial  cells 
of  catarrhal  or  other  forms  of  stomatitis  afford  an  easy  entrance  to 
the  parasite. 

The  statement  in  the  "American  System  of  Dentistry,"  that  this 
disease  does  not  attack  healthy  persons,  but  confines  itself  to 
emaciated  children  and  persons  in  the  last  stages  of  phthisis,  does 
not  agree  with  the  experience  of  Forchheimer,  who  says:  "I  have 
seen  several  instances  in  which  apparently  healthy  infants  have 
been  affected  with  thrush."  The  same  author  also  describes  the 
case  of  a  healthy  child  who  had  thrush,  and  that  of  a  sick  child 
who  was  exposed  to  infection  and  did  not  get  it;  and  he  says:  "As 
far  as  general  good  health  is  concerned,  it  must  be  admitted,  then, 
that  when  it  has  an  effect  upon  the  production  of  thrush  it  must  be 
an  induced  one.     That  such  is  the  case  must  be  admitted  upon 


^6  THE    PRACTICE    OF    DENTAL   MEDICINE. 

close  examination;  the  indirect  effect  is  produced  by  some  change 
in  the  mouth  by  means  of  which  a  proper  soil  is  formed  for  the 
fungus."  At  the  same  time  we  all  know  that  a  depraved  bodily 
condition  in  general  must  favor  the  progress  of  all  diseases,  and 
that  thrush  is  no  exception  to  this  rule.  Moreover,  it  is  well 
known  that  the  disease  is  most  often  found  in  asylums  and  hospi- 
tals for  children.  Cohen  states  that  the  poor  health  of  the  child 
seems  less  accountable  for  the  disease  than  the  unsanitary  condition 
of  buildings  and  surroundings,  and  that  consequently  it  is  much 
less  frequent  in  private  than  in  public  practice. 

Meigs  and  Pepper  consider  the  central  cause  of  this  disease  to 
lie  in  a  failure  of  nutrition,  under  which  the  general  vitality  ebbs 
slowly  away;  and  they  are  inclined  to  the  opinion  that  the  defi- 
ciency in  the  supply  of  water  in  much  of  the  artificial  food  ad- 
ministered to  young  children  is  a  causal  factor  in  producing  this 
disease. 

Pathology. — The  condition  of  the  oral  mucous  membrane  gives 
expression  very  quickly  to  the  invasion  of  thrush.  In  a  few  hours 
masses  of  a  curdy  substance  may  be  seen  adhering  to  the  tissues 
to  the  extent  that  a  slight  bleeding  occurs  when  it  is  forcibly 
removed.  In  children  whose  systems  have  been  much  reduced  by 
previous  disease,  these  masses  often  coalesce  into  a  membraniform 
product,  varying  from  a  gray  or  yellowish  color  to  a  brown,  ac- 
cording as  it  has  been  exposed  to  the  air,  or  from  admixture  of 
blood. 

About  this  time,  the  congestion  of  the  mucous  membrane  sub- 
sides and  it  becomes  comparatively  anemic;  the  deposit  also  be- 
comes less  adherent,  and  after  a  time  it  may  be  removed  easily  by 
the  finger  without  causing  hemorrhage.  The  entrance  of  the 
parasite  is  between  the  epithelial  cells,  separating  one  layer  from 
another  as  the  fungus  develops;  this  development  is  in  the  form  of 
spores  without  mycelium.  From  this  the  parasite  grows  in  both 
directions  toward  the  connective  tissue.  The  growth  thus  begins 
in  small  spots  which  may  or  may  not  become  confluent.  Propaga- 
tion may  go  on  from  the  first  crop,  or  several  places  may  be  in- 
oculated from  the  same  source. 

In  severe  cases  the  patches  enlarge,  forming  masses  with  very 
little  intervening  tissue  not  involved.  The  mucous  membrane  of 
the  tongue  is  usually  first  attacked,  beginning  with  specks  at  the 
tip  and  edges,  thence  spreading  to  the  central  portion  and  to  the 


STOMATITIS    HYPHOMYCETICA.  JJ 

glands  at  its  base.  From  the  tongue  it  extends  to  the  Hps,  cheeks, 
gums,  the  soft  and  the  hard  palate.  The  disease  is  not  limited, 
however,  to  these  structures ;  it  may  cover  the  entire  mucous  mem- 
brane of  the  mouth.  From  the  pharynx  it  may  reach  the  epiglot- 
tis, and  even  the  larynx  (Lelut).  It  has  been  observed  on  the 
vocal  bands  by  Parrot. 

It  has  never  been  observed  about  the  orifices  of  the  Eustachian 
tubes  or  in  the  posterior  nares.  It  seems  that  the  squamous  epi- 
thelium is  most  favorably  formed  for  the  rapid  development  of  this 
parasite.  In  rare  instances  it  has  been  found  in  the  intestinal 
canal  (Seux,  Bouchut,  Robin),  and  oftener  upon  the  nipples  of  the 
nurse. 

Symptoms. — The  earliest  symptom,  in  infants,  is  the  distress 
occasioned  by  nursing,  giving  rise  to  cries  of  pain;  if  the  cry  is 
hoarse,  it  attracts  attention  to  the  vocal  cords  as  being  involved. 
These  outward  expressions  invite  inspection  of  the  mouth,  when 
the  characteristic  lesions,  as  described  under  pathology,  are  ob- 
served. The  subjective  symptoms  vary  with  the  intensity  of  the 
affection;  there  may  be  simple  diarrhea  or  gastro-enteritis,  etc., 
on  the  one  hand,  or  there  may  be  tuberculosis  or  kindred  diseases 
on  the  other,  thus  indicating  the  peculiar  kind  of  constitutional 
predisposition. 

Prognosis. — The  duration  of  the  disease  is  rarely  more  than 
eight  days  in  children  otherwise  strong  and  in  conditions  favor- 
able to  proper  treatment;  but  in  children  who  are  the  subjects  of  a 
constitutional  diathesis  it  may  continue  indefinitely,  the  result 
being  determined  more  by  the  causal  disease  than  the  lesions  in 
the  mouth.  It  will  thus  be  seen  that  the  prognosis  depends  more 
upon  the  patient  than  the  disease  itself.  The  younger  the  child 
and  the  moi  e  extensive  the  eruption,  the  worse  the  prognosis. 

Diag-nosis. — In  infants,  the  examination  of  the  mouth,  after 
noting  that  the  child  is  unable  to  nurse,  reveals  the  inflammatory 
condition  of  the  mucous  membrane.  It  begins  at  the  extremity  of 
the  tongue.  Often  the  tongue  is  very  dry  and  tender  to  the  touch. 
The  secretions  of  the  mouth  are  acid  and  all  its  parts  are  hot  and 
sensitive.  The  microscope,  however,  comes  in  as  a  deciding  factor 
in  the  case,  always  showing  the  presence  of  the  parasite  already 
described. 

Treatment. — The  etiology  of  the  disease,  as  we  have  seen, 
is  in  relation  largely  with  the  digestive  tract,  the  kinds  of  food,  and 


78  THE    PRACTICE    OF    DENTAL    MEDICINE. 

in  infants  with  the  condition  as  to  cleanUness  of  artificial  feeding 
apparatus. 

As  there  is  no  perfect  substitute  for  mother's  milk,  it  is  advisa- 
ble to  secure  a  wet-nurse  rather  than  to  depend  upon  any  form  of 
artificial  food,  or  even  the  milk  of  any  of  the  lower  animals.  The 
next  choice  is  the  use  of  cow's-milk;  which  may  be  modified  as 
follows  (subject  to  change  according  to  the  indications):  Two 
parts  cow's-milk,  one  of  lime-water,  and  one  of  pure  water.  The 
most  scrupulous  care  must  be  exercised  to  secure  cleanliness  of 
the  vessels  in  which  food  is  prepared  and  given.  This  is  impera- 
tive, as  it  is  useless  to  apply  remedies  while  still  supplying  soil  in 
which  the  special  fungus  causing  the  disease  thrives  and  grows. 
If  a  substitute  for  milk  seem  desirable,  it  may  be  found  in  weak 
soups  in  which  there  is  no  sugar  or  casein  to  undergo  fermentation 
and  cause  acidity;  honey  and  syrups  should  be  avoided  for  the 
same  reason. 

In  simple  cases  the  treatment  may  be  largely  local.  It  is 
important  to  remove  the  patches  every  two  or  three  hours  with  a 
soft  cloth  moistened  in  warm  water,  or  in  a  solution  composed  of 
a  teaspoonful  of  sodium  bicarbonate  added  to  a  cup  of  water.  This 
alkaline  wash  serves  the  double  purpose  of  facilitating  the  removal 
of  the  growth  and  neutralizing  the  acidity  of  the  secretions.  Borax 
may  be  added  to  the  above,  or  applied  alone  in  the  proportion  of 
twenty  grains  to  the  ounce  of  water.  The  removal  of  the  patches 
requires  considerable  care  and  dexterity,  and  the  alkaline  wash 
should  be  used  freely  and  often,  so  that  no  force  is  needed  to 
detach  them,  and  it  should  be  borne  in  mind  that  while  it  is  im- 
portant to  remove  these  patches,  roughness  and  undue  haste  must 
be  avoided. 

In  chronic  forms  potassium  chlorate  may  also  be  used  as  a 
wash  for  the  mouth.  iBrandy  and  water  is  an  excellent  application, 
and  may  be  applied  with  a  camel's-hair  brush;  also  applications  of 
listerine  and  glycerol,  equal  parts,  are  serviceable.  Constitutional 
treatment  must  depend  upon  the  symptoms,  or  upon  any  under- 
lying disease  which  may  have  acted  as  a  predisposing  cause.  Cod- 
liver  oil  is  often  indicated  and  may  be  administered  to  children  in 
doses  of  one-half  dram  three  times  daily.  If  there  be  fetor  of 
breath,  and  the  lips  and  gums  are  swollen,  potassic  chlorate  should 
be  given  eveiy  four  hours  in  doses  of  three  grains  each,  dissolved 
in  water. 


STOMATITIS.  79 


ULCERATIVE    STOMATITIS. 


Definition. — Inflamm:.tion  of  the  mouth,  usuahy  unilateral, 
ending  m  ulceration  of  the  mucous  membrane. 

Etiology. — This  form  of  stomatitis  is  closely  associated  with  bad 
hygienic  conditions  such  as  exist  in  crowded  tenement-houses,  or 
scanty  food  and  clothing.  Disease  may  act  as  a  predisposing 
cause,  as  measles  or  scorbutus.  Ulcerative  stomatitis  is  often 
epidemic. 

Pathology. — This  is  a  disease  whose  principal  characteristic  is 
the  formation  of  thick  yellow  patches  of  membrane,  adherent  to 
the  submucus  tissue,  with  inflammation,  erosion,  and  ulceration  of 
the  subjacent  parts.  Although  cancrum  oris  has  sometimes  been 
described  under  this  head,  such  usage  is  hardly  justifiable,  as  the 
character  of  the  ulcer  in  cancrum  oris  is  entirely  different  from  that 
which  is  properly  termed  ulcerative  stomatitis. 

What  is  known  as  membranous  stomatitis  is  most  likely  an 
early  stage  of  the  ulcerative  form,  which,  under  treatment  or  other- 
wise, does  not  proceed  to  ulceration. 

Symptoms. — The  patches  of  membrane  vary  in  appearance  as 
the  disease  progresses,  being  white  at  first,  then  gray,  and  some- 
times at  last  almost  black;  the  surrounding  mucous  membrane  is 
inflamed,  and  if  the  adherent  membrane  is  forcibly  removed  from 
the  patches  in  the  first  stages  it  reveals  an  eroded,  bleeding  surface. 
If  it  goes  on  to  ulceration  the  membrane  becomes  less  adherent 
and  finally  comes  off,  leaving  an  ulcer  with  irregular  red  margins, 
covered  with  a  thick  yellowish  exudation.  Beyond  this  there  are 
no  characteristic  constitutional  symptoms  to  mark  the  progress  of 
the  disease. 

Sometimes  in  young  infants  there  is  slight  fever,  general  lan- 
guor, and  impaired  appetite.  As  the  disease  progresses,  fetor  of 
breath,  salivation,  and  painful  deglutition  are  manifested,  and  the 
mouth  is  hot  and  sensitive  to  the  touch.  Swallowing  of  the  fetid 
saliva  causes  diarrhea;  the  cheeks  sometimes  swell  and  the  sub- 
maxillary and  sublingual  glands  become  inflamed  on  the  affected 
side.  The  other  side  of  the  mouth  may  become  affected,  but 
always  to  a  less  extent.  The  disease  occurs  more  frequently  in 
the  autumn  months. 

Duration. — Without  treatment,  the  disease  is  liable  to  run  on 
for  many  weeks,  or  even  months,  being  influenced  and  prolonged 


8o  THE    PRACTICE    OF    DENTAL    MEDICINE, 

by  intercurrent  diseases;  but  under  proper  care  and  treatment  it 
may  be  limited  to  eight  or  ten  days. 

Prognosis. — The  prognosis  is  good  in  ordinary  cases;  occasion- 
ally the  disease  is  protracted,  suppuration  and  innutrition  bringing 
about  a  fatal  result. 

Diagnosis. — Attention  to  the  pathology,  and  the  remembrance 
that  the  disease  is  usually  unilateral,  will  assist  in  forming  the  diag- 
nosis. Ulcerative  is  distinguished  from  catarrhal  stomatitis  by 
its  peculiar,  fetid  odor;  and  from  cancrum  oris  by  the  absence  of 
induration  of  the  skin  of  the  cheek  over  the  swollen  mucous  mem- 
brane and  by  the  diffuse  character  of  the  swelling.  Ulcerative 
stomatitis  never  extends  beyond  the  cavity  of  the  mouth.  It 
should  be  remembered  that  aphthous  stomatitis  may  coexist  with 
the  ulcerative  form. 

Treatment. — Prophylaxis  is  important  here  as  in  other  forms. 
Cases  should  be  isolated  from  the  rest  of  the  family,  not  so  much 
because  of  the  contagiousness  of  the  disease  itself,  but  because 
other  members  of  the  family,  having  the  same  predisposing  condi- 
tions of  life,  are  especially  susceptible.  They  should  at  the  same 
time  receive  prophylactic  treatment  also.  In  this  disease,  bread 
pills  will  not  answer;  potassium  chlorate  is  the  remedy.  Like 
guaiac  in  quinsy,  potassium  chlorate  seems  to  be  almost  specific 
in  ulcerative  stomatitis.  This  drug  may  be  administered  to  chil- 
dren in  doses  of  two  to  five  grains  three  times  daily,  and  ten  to 
twelve  grains  for  adults.*  A  gargle,  ten  to  twenty  grains  to  the 
ounce  of  water,  may  be  used  with  effect.  A  spray  of  Dobell's 
solution  will  also  be  found  serviceable.  If  the  ulcerated  points 
are  slow  to  heal,  they  should  be  touched  with  a  silver-nitrate  solu- 
tion, ten  grains  to  the  ounce  of  water,  or  with  tincture  of  iodin. 
Trichloracetic  acid  is  also  an  excellent  local  caustic.  So  far  as  the 
writer  has  observed,  the  local  application  of  hydrogen  peroxid  has 
been  of  benefit.  Local  irritants,  as  jagged  edges  of  teeth  or 
necrosed  bone,  should  be  removed.  The  constitutional  treatment, 
as  above  indicated,  in  addition  to  all  that  may  be  comprised  under 
hygiene,  may  include  laxatives  and  general  tonics  and  nutritives 
such  as  iron,  cinchona,  and  cod-liver  oil. 

*  Caution  should  be  exercised  in  administering  potassium  chlorate  to 
infants  and  children,  as  some  are  extremely  susceptible  even  to  minute 
doses.  The  drug  should  be  withdrawn  at  once  when  drowsiness,  suppres- 
sion of  urine,  and  weakness  of  the  heart  are  noticed. 


STOMATITIS.  8l 


GANGRENOUS  STOMATITIS. 

Definition. — A  non-contagious  deuteropathic  inflammation  of 
the  interior  of  the  mouth,  almost  invariably  unilateral,  and  charac- 
terized by  a  peculiar  gangrenous  destruction  of  all  the  tissues  of 
the  cheek  from  within  outward.     (Cohen.) 

Synonyms. — Water  cancer;  Aquatic  cancer;  Cancrum  oris; 
Stomato-necrosis;  Gangrsena  oris;  Necrosis  infantilis;  Noma; 
Gangrenous  erosion  of  the  cheek;  Scorbutic  cancer;  Sloughing 
phagedena  of  the  mouth;  Buccal  anthrax. 

Etiology. — This  is  a  rare  disease,  probably  one  case  in  many 
thousands  of  stomatitis,  and  the  few  cases  found  are  mostly  in 
hospital  practice.  It  occurs  as  a  rule  in  children  from  the  third 
to  the  fifth  year.  Bad  hygienic  conditions,  chronic  illness,  debili- 
tating maladies,  are  among  the  predisposing  causes.  It  is  probably 
not  contagious;  it  may  follow  acute  or  chronic  diseases.  Among 
predisposing  diseases  are  measles,  scarlatina,  whooping-cough, 
typhus  fever,  tuberculosis,  and  mercurial  stomatitis. 

Pathology. — All  the  tissues  forming  the  buccal  wall  are  invaded, 
and  the  ulcerated  parts  slough  off.  As  in  many  other  diseases  of 
the  oral  tissues,  it  is  thought  that  certain  micro-organisms  play  a 
conspicuous  part  in  the  role  of  this  disease.  Froriep*  first  called 
attention  to  the  presence,  in  this  disease,  of  living  organisms  re- 
sembling yeast-fungi.  Grawitzf  found  bacilli  in  nearly  pure  cul- 
ture, which  were  described  by  LoefiflerJ  as  similar  to  the  bacillus 
seen  in  diphtheria  of  calves. 

Post-mortem  examinations  show  the  vessels  of  the  affected 
parts  to  be  filled  with  clots,  thus  accounting  for  the  absence  of 
hemorrhage  in  this  disease. 

Symptoms. — The  disease  is  insidious,  giving  very  little  pain  at 
first,  and  the  symptoms  may  be  masked  by  the  presence  of  some 
other  disease.  Among  the  earliest  and  most  prominent  symptoms 
which  may  be  noticed  are  swelling  of  the  cheek,  fetor  of  breath, 
and  profuse  salivation,  the  swelling  of  the  face  being  specially 
characteristic.  The  skin  appears  to  be  tightly  stretched  over  the 
swelling,  is  red  and  shiny,  with  a  bright  red  spot  in  the  center,  and 
is  very  tender  to  the  touch.     An  examination  of  the  mouth  shows, 

*  "Chirurgische  Kupfertafehi,"  1884. 
t  Deutsche  mcd.  Wochenschrift.  1889. 
j.  Ibid.,  No.  15. 

7 


82  THE    PRACTICE    OF    DENTAL    MEDICINE. 

on  the  buccal  wall  or  on  the  gums,  or  more  frequently  at  the  junc- 
tion of  the  cheek  with  the  gums,  a  small  ulcer,  irregular  in  outline, 
with  jagged  edges  and  with  a  brownish  slough  attached.  The 
edges  are  of  a  bright  red  color  and  bleed  easily.  It  spreads  rapidly, 
conveying  the  same  condition  to  the  adjoining  and  contiguous 
parts.  If  it  begins  in  the  gums  it  spreads  to  the  buccal  walls,  or  if 
it  is  seen  first  on  the  buccal  wall  it  is  observed  to  extend  to  the 
gums,  sometimes  loosening  the  teeth  so  that  they  fall  out. 

As  the  ulcerative  process  goes  on  in  the  mouth,  the  external 
swelling  changes  also;  the  bright  red  spot  in  the  center  of  the 
swelling  increases  in  size,  and  changes  from  a  livid  coliDr  to  one 
that  is  quite  black.  This  increases  in  area,  and  the  destruction  of 
tissue  goes  on  until,  usually  within  seven  days,  the  slough  is  thrown 
off.  Death  may,  however,  take  place  before  the  cavity  of  the 
mouth  is  laid  open. 

Prognosis." — The  prognosis  is  generally  unfavorable,  depending 
upon  the  stage  of  the  disease  at  which  treatment  is  instituted. 
Early  operative  or  medical  treatment  offers  a  hope,  while  the 
untreated  cases  nearly  always  terminate  fatally. 

Treatment. — The  treatment  is  both  local  and  constitutional. 
Early  local  measures  are  very  important;  these  consist  in  applying 
to  the  ulcers  strong  trichloracetic  or  nitric  acid  by  means  of  a 
pointed  glass  rod  or  a  bit  of  lint  twisted  on  the  end  of  a  stick; 
being  careful  not  to  burn  healthy  tissue,  while  at  the  same  time 
the  ulcers  should  be  most  thoroughly  cauterized,  after  which  an 
antiseptic  wash  should  be  used;  for  instance: 

5 — Acidi  carbolici,  gtt.  xv: 

Aquae,  §iv.  M. 

Sig.— Mouth-wash. 

After  rinsing  the  mouth,  a  piece  of  lint  soaked  in  the  wash 
should  be  left  applied  to  the  ulcers  for  about  four  hours,  when  it 
should  be  changed  and  the  parts  again  washed. 

The  constitutional  treatment  consists  in  tonics,  good  nourish- 
ment, and  stimulants.  Potassium  chloiate  may  be  given  in  doses 
of  from  three  to  ten  grains.  Very  likely  purgatives  will  be  neces- 
sar}',  and  castor  oil  is  commended  as  one  of  the  most  efificient. 
If  the  ulcer  continues  to  spread,  it  will  need  another  application  of 
acid.  The  condition  of  the  ulcer  indicates  the  severity  and  prog- 
ress of  the  disease.  Surgical  treatment,  if  instituted  early,  offers 
some  hope;  it  consists  in  the  removal  of  the  diseased  tissues. 


DIPHTHERIA.  83 

CHAPTER    XII. 
DIPHTHERIA. 

Definition. — An  acute  contagious  and  epidemic  disease  with  the 
principal  local  manifestation  in  the  throat,  accompanied  by  sys- 
temic poisoning. 

Etiology. — There  is  a  specific  poison  for  diphtheria, — the 
Klebs-Loeffier  bacillus,  which  produces  the  disease  whenever  the 
necessary  conditions  prevail.  Diphtheria  is  highly  contagious. 
The  poison  exists  principally  in  the  secietions  of  the  throat,  and  it 
is  probably  through  this  agency  that  the  disease  is  communicated. 
The  medical  attendant  or  the  nurse  may  receive  the  breath  or 
particles  of  mucus  while  the  patient  is  coughing,  and  thus  contract 
the  disease.  Articles  of  clothing  may  carry  the  poison  for  a  long 
distance,  and  retain  it  for  a  long  time.  A  common  drinking-cup, 
children's  playthings,  such  as  whistles,  harmonicas,  etc.,  may  be 
the  means  of  conveying  the  disease.  The  period  of  incubation 
varies  from  two  to  eight  or  ten  days. 

Symptoms. — In  the  simple  or  catarrhal  form  the  disease  begins 
much  as  a  common  cold,  with  more  or  less  malaise,  dullness,  slight 
fever,  and  headache.  The  throat  is  irritated  and  usually  painful. 
In  more  severe  cases  these  symptoms  are  very  pronounced,  with 
the  addition  of  nausea  and  vomiting. 

On  inspection  of  the  throat,  the  tongue  is  seen  to  have  a  thick 
white  coating.  The  palate  and  tonsils  reveal  grayish-white  patches, 
thin  and  firmly  attached.  These  patches  increase  in  size  and 
coalesce,  at  the  same  time  becoming  thicker,  the  margin  being 
distinctly  outlined  against  the  deep  red  mucous  membrane. 

In  the  croupous  form  of  this  disease  there  is  likely  to  be  a  sud- 
den rise  in  temperature,  a  spreading  and  thickening  of  the  mem- 
brane, and  enlargement  of  the  cervical  glands.  The  SAvelling  of 
the  neck  may  reach  an  enormous  size,  and  the  secretion  of  the 
affected  glands  is  offensive,  which  with  the  other  decomposing 
secretions  gives  to  the  breath  an  extremely  offensive  odor.  These 
and  the  products  of  decomposition  may  enter  the  blood  and  pro- 
duce septicemia. 

Diagnosis. — Take  a  scraping  from  the  throat  in  the  vicinity  of 


84  THE    PRACTICE    OF    DENTAL    MEDICINE. 

the  patches  or  over  them,  by  means  of  a  steriHzed  platinum  point, 
and  after  rubbing  it  on  the  culture  medium  provided  for  this  pur- 
pose, return  the  latter  to  the  bottle  or  receptacle,  and  send  it 
to  some  expert  or  agent  of  the  board  of  health  to  be  examined. 
The  presence  of  the  bacilli  determines  the  diagnosis.  This  disease 
may  be  confounded  with  acute  follicular  tonsillitis,  which,  however, 
may  be  distinguished  from  diphtheria  by  the  appearance  of  small 
ulcers,  corresponding  to  as  many  follicles  in  the  tonsil,  that  con- 
tain a  white,  cheesy  secretion.  The  superficial  portions  of  these 
small  ulcers  are  easily  detached,  which  is  not  the  case  in  diphtheria. 

The  diphtheritic  membrane  is  tough  and  leathery,  firmly  ad- 
herent, and  if  removed  it  forms  again.  The  white  spots  of  aphthous 
stomatitis  begin  on  the  lips  and  tip  of  the  tongue  and  spread  back- 
ward, while  in  diphtheria  the  patches  are  situated  on  the  posterior 
wall  of  the  pharynx  and  tonsils,  and  spread,  if  at  all,  forward.* 

Treatment. — The  principles  of  treatment  include  keeping  the 
nose  and  mouth  disinfected  by  means  of  a  spray  or  douche  with 
some  antiseptic  solution.  The  mouth  should  be  rinsed  frequently, 
and  the  throat  gargled.  The  secretions  should  be  isolated  and 
destroyed,  as  in  these  lies  the  danger  of  contagion. 

Stimulants  and  nourishment  should  be  used  freely.  Local 
applications  which  have  an  especial  effect  on  the  membrane  are  of 
service.  Lactic  acid  and  water,  well  diluted,  so  that  it  has  only  a 
slightly  acid  taste,  may  be  used  with  a  swab  or  sprayed  into  the 
throat  by  means  of  an  atomizer,  after  which,  powdered  sulfur 
may  be  applied  by  means  of  a  powder-blower.  Tincture  of  the 
iron  chlorid  has  been  much  used  in  the  same  way  as  the  lactic 
acid;  it  may  be  also  administered  internally. 

There  seems  to  be  no  doubt  that  "antitoxin"  exerts  a  marked 
influence  on  the  disease,  and  that  it  has  reduced  the  mortality  to  a 
great  extent. 

Formaldehyde  gas  is  not  only  accepted  as  the  best  disinfectant 
for  rooms,  but  it  has  been  used  successfully  during  the  course  of 
the  disease.  Formaldehyde  is  a  gaseous  product  of  the  oxidation 
of  methyl  alcohol,  and  a  solution  containing  forty  per  cent,  of  the 
gas  is  furnished  under  the  name  of  "formalin"  or  "formol,"  of 
which  I  part  to  200  of  water  may  be  used  in  the  mouth. 

*It  is  important  that  the  dentist  be  able  to  diagnose  diphtheria;  to 
differentiate  it  from  aphthous  stomatitis;  that  he  be  aware  of  the  facility 
by  which  it  may  be  propagated  from  one  person  to  another;  that  he  govern 
himself  accordingly. 


SCURVY.  85 

CHAPTER    XIII. 

SCURVY. 

Synonym. — Scorbutus. 

Definition. — A  general  disease,  characterized  by  malnutrition 
and  having  a  marked  local  expression  in  the  mouth ;  brought  about 
by  living  upon  one  kind  of  food,  or  food  deficient  in  vegetable 
matter. 

Etiology. — There  have  been  a  great  many  theories  proposed  as 
to  the  cause  of  the  condition  known  as  scurvy.  Of  these,  de- 
pressing mental  influences  and  despondency  were  often  connected 
with  the  disease.  But  in  this  the  mistake  was  probably  made  of 
placing  these  mental  conditions  as  causative  rather  than  as  an  ac- 
companiment of  the  disease.  Much  evidence  goes  to  show  that  no 
degree  of  mental  exhilaration  could  ward  off  the  disease  while  the 
determining  causes  are  acting;  neither  could  any  degree  of  mental 
despondency  induce  it  while  proper  food  was  taken. 

Various  atmospheric  qualities  were  at  one  time  regarded  as 
being  active  causes;  impurities  such  as  exist  in  the  holds  of  ships, 
and  in  crowded  habitations  or  cities,  being  appropriate  examples. 
Observers  as  early  as  the  seventeenth  century  considered  cold,  also, 
as  an  active  cause  of  scurvy,  especially  when  combined  with  damp- 
ness. On  the  other  hand,  a  very  high  temperature  has  been  con- 
sidered a  cause.  Again,  authorities  have  held  responsible  for  it 
excessive  exertion  followed  by  great  fatigue  and  exhaustion ;  while, 
in  contrast  to  this,  equally  good  authorities  have  placed  consider- 
able emphasis  upon  indolent  habits  and  lack  of  exercise  as  a  de- 
termining cause  of  the  disease.  Most  observers,  however,  have 
studied  the  food  and  drink  question  in  order  to  find  the  exciting 
causes  of  scurvy,  and  in  the  study  of  this  question  many  opinions 
have  been  advanced,  which  it  seems  unnecessary  to  enumerate 
here. 

When  this  disease  occurred  on  land  it  seemed  somewhat  differ- 
ent from  scurvy  occurring  at  sea,  and  the  fact  of  its  frequency  on 
shipboard  brought  out  the  erroneous  opinion  that  sailors'  diet  and 
its  saline  materials  were  active  in  causing  scurvy.  This  idea  has 
now  been  discarded  by  numerous  authors,  who  have  concluded 
that  the  chief  cause  of  scurvy  lies  in  a  deficiency  of  vegetable  food, 


86  THE    PRACTICE    OF    DENTAL    MEDICINE. 

especially  of  the  fresh,  succulent  kind.  A  consideration  of  the 
treatment  of  this  disease  will  bring  out  the  fact  that  the  food  of  the 
patients  has  been  lacking  in  variety.  Especially  is  this  the  case 
with  scorbutic  children  whose  diet  consists  mainly  of  one  article 
of  food. 

Dr.  Thomas  Buzzard  makes  two  statements  which  are  inter- 
esting and  conclusive:  "There  is  no  case  on  record  of  scurvy 
occurring  in  a  person  who  has  been  adequately  supplied  with 
fresh,  succulent  vegetables  of  good  quality.  The  occurrence  of 
scurvy  in  persons  living  upon  salt  meats  may  be  prevented  by  the 
regular  administration  of  fresh  vegetables  or  the  juice  of  lemons." 
Barlow  sums  up  the  etiology  of  this  subject  in  -the  following: 
"The  prolonged  use  of  a  defective  diet  induces  the  symptoms." 

Pathology. — The  particular  morbid  appearances  which  are 
present  in  scurvy  occurring  in  infants  and  children  is  illustrated  by 
the  following  cases. 

The  first  was  a  child  of  thirteen  months,  apparently  well  nour- 
ished, presenting  dark  cherry-red  tumors  hanging  over  the  par- 
tially erupted  incisor  teeth  of  both  jaws.  The  surface  of  these 
tumors  was  tough  and  shiny,  not  having  a  tendency  to  bleed,  but 
a  free  hemorrhage  followed  an  incision  into  them.  There  were  no 
hemorrhagic  spots  on  any  other  part  of  the  body,  but  the  lower 
extremities  presented  marked  rheumatic  symptoms.  A  change 
was  made  in  the  diet,  from  Mellin's  food  (which  had  been  exclu- 
sively given)  to  broths,  with  the  addition  of  grape-juice.  The  re- 
covery was  so  rapid  and  pronounced  that  there  was  no  room  for 
doubt  as  to  the  diagnosis.* 

At  the  present  time,  however,  errors  in  diagnosis  are  less  fre- 
quently made,  and  the  disease  is  more  commonly  recognized  since 
the  eleven  cases  reported  by  Northrup  in  1891,  followed  by  those 
of  Rotch,  Starr,  and  others. 

One  of  the  cases  reported  by  Dr.  I.  N.  Love,  at  the  meeting  of 
the  American  Medical  Association  at  Baltimore  in  May  1895,  is  of 
interest.  It  related  to  twins,  eight  months  old.  Both  had  a  his- 
tory of  marasmus.  The  food,— consisting  of  cow's-milk,  boiled 
and  diluted  largely  with  water  or  lime-water, — and  the  surround- 
ings and  conditions  were  all  exactly  alike  in  both  cases,  yet  one 
child  developed  scurvy  and  the  other  did  not.     It  is  significant 

*  From  remarks  by  the  writer  published  in  the  Boston  Medical  and 
Surgical  Journal. 


SCURVY.  87 

that  while  the  child  suffering  from  scurvy  died  in  three  days  from 
the  time  he  was  seen  by  Dr.  Love,  the  surviving  patient,  being  put 
upon  antiscorbutic  remedies,  began  to  thrive  and  soon  became  well 
nourished.  Dr.  Love  also  states  that  in  this  case  the  gums  were 
spongy,  with  a  tendency  to  bleed,  though  no  teeth  had  yet  ap- 
peared. 

It  would  seem  that  the  otherwise  normal  irritation  attending 
the  eruption  of  the  teeth  is  necessary  to  produce  the  spongy  growth 
of  the  gums  when  a  tendency  to  scurvy  exists.  In  other  words, 
scorbutic  infants  before  the  eruption  of  the  teeth  present  a  normal 
appearance  of  the  gums,  or  the  growth  may  appear  at  the  site  of 
the  erupting  teeth,  while  in  those  parts  of  the  jaw  in  which  there 
are  no  teeth  the  gums  are  normal. 

In  this  case  of  Dr.  Love's,  while  the  teeth  were  not  fully 
erupted,  the  process  of  eruption  was  probably  going  on,  for  we 
should  note  that  the  eruption  of  the  incisor  teeth  usually  occurs 
between  the  seventh  and  ninth  months,  and  this  child  was  then 
eight  months  old.  '  It  would  be  difficult,  of  course,  to  state  just 
how  far  advanced  the  process  of  tooth-eruption  must  be,  in  order 
to  produce  the  characteristic  local  expression  on  the  gums;  that 
would  depend  upon  the  susceptibility  in  each  individual  case,  but 
this  factor  should  be  taken  into  consideration  when  statements  are 
made  that  no  outgrowth  or  spongy  condition  of  the  gum  appears 
before  the  eruption  of  the  teeth. 

Symptoms. — The  symptoms  in  a  case  of  scurvy  are  few,  but  very 
marked  and  characteristic.  One  of  the  earliest  is  a  change  in  the 
color  of  the  skin,  which  presents  a  pale,  sallow,  or  greenish  tint. 
It  will  be  noticed  that  the  patient  is  listless,  with  an  aversion  to 
exercise.  Upon  inquiry,  the  appetite  may  be  found  to  be  defective; 
sometimes  fairly  good,  in  other  cases  entirely  wanting,  depending 
much  upon  the  stage  of  the  disease.  The  tongue  is  heavily  coated, 
the  breath  fetid,  and  the  gums  are  exceedingly  painful  to  the  touch, 
often  bleeding  easily.  This,  together  with  the  swelling,  interferes 
with  mastication  so  that  the  patient  eats  little  or  nothing.  In  most 
cases  there  is  some  constipation.  Another  characteristic  symptom 
is  the  condition  of  the  lower  extremities,  which,  according  to  the 
writer's  experience,  is  decidedly  rheumatic,  and  if  the  disease  is 
allowed  to  advance,  swelling  may  occur  in  the  flexures  of  the 
joints.  There  is  no  fever  and  the  patient  usually  sleeps  well.  If 
the  case  is  well  advanced,  petechiye  are  observed,  more  commonly 


88  THE    PRACTICE    OF    DENTAL    MEDICINE. 

about  the  legs  and  thighs;  they  are  small  and  of  a  reddish-brown 
color.  If  the  disease  still  progresses,  these  spots  are  likely  to  in- 
crease in  size.  An  additional  symptom  is  that  the  patient  gets  out 
of  breath  without  apparent  cause. 

Some  cases  of  scurvy  have  been  reported  in  which  the  gums 
have  been  normal,  but  these  cases  must  be  rare. 

Prognosis.- — The  prognosis  is  generally  favorable,  but  much 
depends  upon  early  treatment  and  the  extent  to  which  vital  organs, 
as  the  brain,  heart,  and  lungs,  are  involved. 

Diagnosis. — The  diagnosis  may  be  established  upon  observance 
of  the  following :  A  history  of  defective  diet,  usually  that  in  which 
one  article  has  been  the  chief  food.  The  body  may  be  plump  but 
with  a  decided  anemic  appearance;  there  may  be  coated  tongue, 
fetid  breath,  and  rheumatic  symptoms  in  the  lower  extremities, 
varying  from  pseudo-paralysis  to  stififness  of  the  joints,  and  increas- 
ing to  such  an  extent  that  there  is  much  pain  upon  the  slightest 
movement  of  the  limbs.  The  appearance  of  the  gums  is  character- 
istic. They  are  often  swollen  to  a  great  extent,  and  in  the  form  of 
tumors  in  the  location  of  erupting  or  "erupted  teeth,  sometimes  pre- 
senting a  hard,  shiny  appearance,  and  in  other  cases  bleeding  upon 
the  slightest  touch.  These  swellings  or  tumors  occur  only  around 
the  teeth.  Finally,  the  diagnosis  is  complete  when  notice  is  taken 
of  the  almost  magical  improvement  under  the  use  of  antiscorbutic 
remedies. 

Treatment. — The  treatment  is  very  simple.  In  the  case  already 
given,  that  of  a  child  thirteen  months  old,  the  only  treatment  con- 
sisted in  a  change  from  Mellin's  food,  which  had  been  exclusively 
taken,  to  grape-juice  and  fresh  cow's-milk.  Another  case  was  that 
of  a  girl  twelve  years  of  age,  who  had  been  boarding  at  an  hotel  in 
the  White  Mountains,  where  she  had  partaken  freely  and  con- 
stantly of  meats.  Although  fresh  air  and  exercise  were  not  lack- 
ing, a  marked  case  of  scurvy  was  the  result.  The  only  treatment 
consisted  in  a  few  doses  of  calomel  of  one-tenth  of  a  grain  each,  and 
a  diet  in  which  for  meat  there  were  substituted  fresh  vegetables, 
milk,  etc.  The  patient  drank  freely  of  grape-juice.  At  the  end  of 
forty-eight  hours  a  marked  change  for  the  better  was  noted,  and  at 
the  end  of  six  days  the  gums  approximated  a  normal  appearance. 
The  swelling  of  the  gums  in  this  case  was  such  that  large  portions 
required  amputation  in  order  that  the  patient  might  bring  the  teeth 
together  in  mastication. 


"p«s»^ 


SCURVY.  89 

The  following  case,  described  by  Dr.  Albert  H.  Burr  of  Chicago, 
presents  so  many  points  of  interest  that  the  writer  takes  pleasure  in 
quoting  freely  from  it: 

Dorothy  R.,  thirteen  and  a  half  months  old,  had  been  brought  to 
Chicago  from  a  distant  State,  by  the  advice  of  the  family  physician,  to  be 
treated  for  a  supposed  spinal  trouble.  She  was  placed  under  the  care  of 
one  of  our  best  orthopedists.  The  diagnosis  was  rhachitis,  with  slight 
spinal  curvature.  As  the  child  was  too  weak  for  any  corrective  appliances 
the  specialist  addressed  himself  to  general  tonics  and  restoratives  with  the 
view  of  improving  the  anemia  and  malnutrition.  At  the  end  of  six  weeks 
the  child,  which  at  first  seemed  to  be  materially  improved,  was  found  to  be 
decidedly  worse,  and  for  two  weeks  had  not  been  able  to  lift  its  head  from 
the  pillow.  Emaciation  was  progressive,  and  the  specialist  expressed  the 
opinion  that  the  case  was  hopeless  and  the  child  must  soon  die  from  maras- 
mus. 

The  history  as  given  by  the  mother  was  this:  Up  to  eight  months  of 
age  the  child  appeared  well  nourished  and  in  the  best  of  health.  About 
this  tim.e  it  became  fretful,  grew  pale,  and  began  to  lose  flesh.  Purple 
spots  appeared  over  its  shoulders,  back,  and  thighs,  which  suppurated  and 
many  of  them  were  lanced,  leaving  marks  similar  to  the  pitting  of  small- 
pox. The  lower  extremities  were  painful  on  being  handled  and  the  child 
ceased  to  move  them  voluntarily.  Its  diet  from  birth  had  been  Mellin's 
food  exclusively.  The  mother  had  lost  her  ability  to  nurse  on  account  of 
multiple  abscesses  of  her  breasts  at  a  previous  birth. 

At  this  time  the  child  was  very  anemic  and  much  emaciated,  weighing 
but  thirteen  and  a  half  pounds.  It  could  not  lift  its  head  or  move  its 
body  or  thighs,  and  was  handled  on  a  pillow.  The  right  femur  and  left 
scapula  were  perceptibly  swollen.  Dentition  was  delayed.  The  upper  and 
lower  middle  incisors  only  were  erupted,  and  these  were  almost  hidden  by 
spongy  ecchymotic  gums.  In  the  roof  of  the  mouth  was  a  purplish  tumor 
with  an  eroded  apex.  The  fetor  of  its  breath  was  marked.  The  body  was 
bathed  in  sweat.  The  stools  were  hard  and  variegated  in  light  drab  and 
dark  slate  colors,  with  an  offensive  odor  like  that  of  a  carnivorous  animal. 
The  child  cried  with  pain  on  being  handled  and  was  fretful  and  wakeful 
during  the  nights.  This  array  of  symptoms  completed  a  picture  of  pitiful 
distress.' 

Treatment. — The  food  was  changed  at  once  to  fresh  cow's-milk  and 
barley  flour  as  a  basis.  Orange-juice  and  raw  scraped  beef  were  given 
daily,  which  the  child  took  with  the  greatest  avidity.  Scraped  apple  and 
tender  sprigs  of  fresh  lettuce  and  cabbage  were  also  allowed  by  way  of 
variety.  A  cool  sponge  bath  at  75°  F.,  with  gentle  friction,  was  given  every 
morning  for  its  tonic  effect.  To  change  the  character  of  the  stools  and 
disinfect  as  far  as  possible  the  intestinal  tract,  calomel  tablets,  Vio  of  a  grain 
every  two  hours,  and  a  powder  composed  of  guaiacol  carbonate,  Vc  of  a 
grain,  and  protonuclein,  one  grain  every  four  hours,  were  ordered  given. 
Hydrolein  was  administered  three  times  daily  for  its  alterative  and  recon- 
structive properties.     The  improvement,  even  in  so  short  a  time  as  twenty- 


go  THE    PRACTICE    OF    DENTAL   MEDICINE. 

four  hours,  was  gratifying  and  astonishing.  At  the  end  of  forty-eight  hours 
the  character  of  the  stools  was  changed,  the  fetor  of  the  breath  had  disap- 
peared, and  the  child  was  inclined  to  amuse  itself.  After  the  fourth  day  it 
could  lift  its  head,  and  its  nights  were  restful.  At  the  end  of  the  first  week 
all  traces  of  spongy  gums  and  sore  mouth  had  disappeared;  it  began  to 
laugh  and  crow  and  exercise  its  limbs  and  thighs,  and  no  longer  dreaded 
handling.  At  the  end  of  the  second  week  it  had  gained  one  pound;  could 
lift  its  feet  above  its  head  for  the  first  time  in  several  months.  All  remedies, 
except  hydrolein  and  occasional  doses  of  mild  chlorid,  were  now  discon- 
tinued. A  soft-boiled  egg  with  rolled  cracker  was  allowed  every  other  day, 
alternating  the  scraped  beef.  Third  week:  Anemia  has  disappeared.  Can 
sit  alone.  Has  erupted  upper  lateral  incisors.  Three  weeks  ago  there  were 
no  signs  of  these  teeth.  Is  taken  out  daily  for  exercise.  Fourth  week: 
Has  gained  in  weight,  rolls  about  on  the  rug  and  tries  to  creep.  Dis- 
charged cured  and  returned  home  at  end  of  six  weeks.  A  change  like  this, 
after  six  months  of  helplessness  and  untold  suffering,  seems  little  less  than 
magical. 

The  points  of  interest  in  this  case  are:  The  supposed  suppuration  of 
the  hemorrhagic  lesions,  which  the  family  physician  diagnosed  and  treated 
as  eczema;  the  swelling  over  the  femur  and  scapula,  and  slight  curvature 
of  lumbar  region,  diagnosed  and  treated  for  six  weeks  by  a  noted  ortho- 
pedist as  rickets,  and  lastly  the  rapid  recovery  under  antiscorbutic  treat- 
ment. 

The  foremost  problem  in  the  consideration  of  every  disease  is  how  to 
prevent  it.  Scorbutus  is  a  preventable  disease.  How  shall  we  guard 
against  and  limit  this  recently  diagnosed  and  apparently  increasing  dis- 
order? We  shall  not  find  it  in  the  homes  of  the  poor,  nor  among  the 
laboring  classes,  so  often  as  among  the  well-to-do  and  in  the  houses  of 
affluence,  for  the  mothers  in  the  commoner  walks  of  life  more  uniformly 
suckle  their  babes,  and  this  is  prophylactic.  Barlow  says:  "In  no  single 
case  at  the  time  of  the  malady  has  the  child  been  breast-fed." 

1.  Woman  herself  should  be  physically  prepared  for  better  mother- 
hood, so  that  she  may  be  capable  of  yielding  her  offspring  the  only  food 
nature  intended  for  it. 

2.  Mothers  should  be  impressed  with  the  fact  that  there  is  no  perfect 
substitute  for  breast-milk,  and  that  next  to  the  right  of  being  well  born,  the 
babe  has  an  inalienable  right  to  nature's  food,  and  no  trivial  excuse  or  sur- 
mountable difficulty  should  hazard  its  life  or  health. 

3.  If  for  any  reason  the  breast-milk  is  inadequate,  or  has  entirely  failed, 
the  ne'&.rest  approach  to  it  is  to  be  found  in  the  modified  cow's-milk  of  our 
modern  laboratories,  or  the  home  modification  of  cow's-milk  after  the  plans 
given  by  Rotch  in  his  recent  and  most  valuable  work  on  pediatrics. 

4.  Above  all,  no  continuous  administration  of  any  sterilized,  Pasteur- 
ized, peptonized,  or  condensed  milk  or  any  dry  commercial  food  should  be 
given  to  the  exclusion  of  fresh  or  raw  elements  of  diet.  In  what  this  anti- 
scorbutic property  consists,  which  is  found  in  fresh  foods  and  is  lacking  in 
the  artificially  prepared  and  manipulated  foods,  is  not  yet  determined,  but 
it  is  more  than  likely  that  the  important  offices  performed  by  the  normal 


RHACHITIS.  91 

germs  of  the  gastro-intestinal  tract  in  the  complicated  processes  of  diges- 
tion are  incapable  of  being  completed  with  artificial  food,  and  thus  putre- 
factive changes  in  imperfectly  digested  pabulum  lead  to  auto-infection  and 
malnutrition. 


CHAPTER    XIV. 

RHACHITIS. 


Synonyms. — Some  of  the  more  common  synonyms  are: 
Rickets;  Rhachitismus;  Osteomalacia;  Spina  nodosa. 

Definition. — A  disease  occurring  in  infancy  and  early  childhood, 
characterized  by  a  deficiency  in  growth  and  quality  of  the  bones, 
resulting  in  deformities,  etc. 

Etiology. — The  primal  cause  of  this  disease  may  be  stated  in 
one  word, — mal-assimilation.  It  occurs  frequently  among  the 
poor  and  ill-fed,  but  it  also  occurs  among  the  well-to-do.  A  pre- 
disposition to  this  disease  is  undoubtedly  inherited.  High  and 
fashionable  life,  as  well  as  bad  hygiene  and  extreme  poverty, 
depress  the  bodily  powers  of  the  mother,  and  tend  to  the  produc- 
tion of  rickety  children.  While  rhachitis  may  occur  in  any  part  of 
the  world,  it  is  rarely  found  in  tropical  regions,  though  frequent 
in  low,  damp  situations.  It  is  said  to  be  more  common  in  Europe 
than  in  this  country. 

Pathology. — This  disease  may  be  congenital,  but  the  more 
marked  characteristics  are  shown  as  the  child  is  developing.  The 
imperfect  calcification  of  the  bones  results  in  certain  deformities 
which  are  very  apparent,  as  seen  in  the  contracted  chest,  distorted 
spine,  and  bow-legs.  In  the  deficiency  of  bone-development  the 
teeth  share  in  the  general  misfortune;  indeed,  the  teeth  are  among 
the  first  tissues  to  be  affected,  as  not  only  retarded  dentition  but 
irregularities  of  the  teeth  are  a  marked  characteristic  of  rhachitic 
children.  The  tooth-form  is  also  apt  to  be  irregular,  and  it  is  often 
diminutive  in  size.  The  structure  of  these  rhachitic  teeth  is  such 
that  caries  rapidly  develops. 

Symptoms. — Some  of  the  above  pathological  conditions  may 
also  be  classed  as  symptoms;  in  addition  it  may  be  stated  that 
children  suffering  from  rhachitis  are  observed  to  perspire  easily, 


92  THE    PRACTICE    OF    DENTAL    MEDICINE. 

and  are  irritable  in  temper.  There  is  general  emaciation  due  to 
indigestion  and  the  consequent  intestinal  disturbances.  The  appe- 
tite is  either  depraved  or  lacking,  and  sometimes  vomiting  occurs. 
The  child  is  often  unable  to  walk,  and  is  generally  indisposed  to 
any  exertion.  There  is  usually  tenderness  along  the  spine  and  in 
other  parts  of  the  body.  The  wearied  and  aged  countenance  is 
also  characteristic. 

Treatment. — The  main  object  in  treatment  is  to  secure  proper 
nutrition.  To  this  end  good  hygienic  conditions  must  be  obtained. 
The  clothing  should  be  warm,  and,  if  the  child  is  nursing,  special 
attention  should  be  given  to  the  milk.  If  the  mother  be  afifected 
with  syphilis  or  a  cachexia  she  should  not  nurse  the  child,  although 
the  milk  is  healthful.  If  a  good  wet-nurse  cannot  be  had,  it  is 
important  that  the  best  substitute  should  be  provided,  which  is 
probably  cow's  milk  to  which  is  added  one-fourth  part  of  lime- 
water.  Cod-liver  oil  is  one  of  the  most  potent  remedies  that  can 
be  employed  in  this  condition.  The  hypophosphites  of  lime  and 
soda  are  also  very  efificient,  and  often  small  doses  of  iron  are 
indicated. 

Subjects  of  this  disease  should  not  be  allowed  to  creep  or  walk 
too  early. 


CHAPTER    XV. 

SCROFULA. 


Synonyms. — Struma;  Scrofulosis;  King's  evil;  The  evil;  Tuber- 
culosis. 

Definition. — A  constitutional  dyscrasia,  hereditary  or  acquired, 
characterized  by  glandular  swellings  and  different  grades  of  inflam- 
mation. 

Etiology. — Probably  the  most  important  factor  in  the  causation 
of  this  disease  is  heredity.  Parents  who  are  not,  strictly  speaking, 
scrofulous  may  transmit  to  their  offspring  a  strumous  condition. 
Scrofula  may  be  acquired  through  the  evil  influences  of  bad 
hygienic  surroundings,  such  as  poor  food,  insufBcient  clothing, 
overwork,  crowding  together  in  small,  low,  damp  rooms,  etc. 
Again,  this  disease  may  be  transmitted,  especially  if  there  be  a  pre- 
disposition to  it,  by  means  of  milk  from  tuberculous  cows.     It 


SCROFULA.  93 

seems  reasonable  to  suppose  that  carelessness  in  neglecting  the 
destruction  of  discharges  from  glandular  swellings  may  cause  the 
disease.  This  would  be  especially  true  of  tuberculous  diseases  of 
the  lungs,  or  phthisis  pulmonalis.  In  this  disease,  the  sputa  being 
deposited  on  sidewalks,  floors,  public  conveyances,  etc.,  is  dried, 
converted  into  dust,  and  carried  hither  and  thither  by  movements 
of  the  air.  These  particles  containing  the  bacillus  tuberculosis  are 
inhaled,  the  person  becomes  infected,  and  if  he  is  peculiarly  sus- 
ceptible the  disease  is  thus  developed.  It  is  possible  that  tubercu- 
losis may  be  communicated  during  dental  operations  when  the 
bacilli  in  the  mouth  of  a  patient  may  infect  the  operator.  In  view 
of  these  possibilities  the  dentist  should  take'warning. 

The  disease  usually  manifests  itself  in  children  about  the  time 
when  the  temporary  teeth  begin  to  appear,  and  the  liability  in- 
creases up  to  the  seventh  year.  Certain  diseases  are  supposed  to 
be  predisposing  causes,  as  measles,  whooping-cough,  smallpox, 
typhoid  fever,  etc. 

Symptoms. — Scrofulous  subjects  are  usually  susceptible  to  in- 
flammation of  the  eye  and  ear,  and  also  to  enlargement  of  the  fau- 
cial  and  pharyngeal  tonsils  accompanied  by  nasal  catarrh.  Slight 
wounds  in  the  skin  heal  slowly,  and  eruptions  often  occur  on  the 
face  and  scalp.  During  the  temporary  dentition,  the  lymphatic 
glands  are  disposed  to  swell,  and  often  break  down  by  cheesy 
degeneration,  discharging  pus.  The  healing  of  these  abscesses 
takes  place  with  difficult}',  often  presenting  deep  excavations  hav- 
ing thick  and  indurated  margins.  Sometimes  the  glands  may 
enlarge  without  suppuration. 

Effects  on  the  Teeth. — Certain  peculiarities  of  the  teeth  are 
closely  associated  with  this  disease;  but  the  cases  in  which  tooth 
symptoms  appear  are  generally  those  in  wdiich  the  condition  is 
inherited.  In  these  cases  the  teeth  present  a  perfect  form  and 
structure.  Imperfections  in  development  vary  much  in  different 
individuals;  sometimes  presenting  white  spots  on  the  surface  of  the 
teeth,  which  finally  soften  and  decay;  sometimes  being  notched  or 
serrated  in  their  cutting  edges,  or  contracted  in  form,  presenting  a 
stunted  appearance.  In  fact,  no  particular  type  of  deformity  can 
be  described  as  being  associated  with  this  disease,  for  the  disease 
itself  presents  many  phases  and  is  little  understood.  Its  relation 
to  syphilis  has  been  suspected,  and  is  held  by  many  to  be  closely 
associated  with  it.     It  is  impossible  to  designate  certain  typical 


94  THE    PRACTICE    OF    DENTAL   MEDICINE. 

defects  of  the  teeth  as  belonging  to  scrofula  and  another  distinctive 
type  as  belonging  to  syphilis. 

Effect  of  a  Scrofulous  Diathesis  on  certain  Dental  Diseases. — The 
existence  of  a  scrofulous  diathesis  is  sure  to  act  unfavorably  in  the 
treatment  of  many  pathological  conditions  of  the  mouth  and  teeth. 
For  example,  pulpitis  is  more  likely  to  go  on  to  suppuration  and 
death  of  the  pulp,  and  alveolar  abscess  is  more  difficult  to  cure. 
Gingivitis  and  the  various  forms  of  stomatitis  are  much  slower  in 
their  response  to  treatment.  Particularly  is  this  the  case  in  many 
of  the  antrum  diseases,  which  may  go  on  for  years,  yielding  to 
treatment  only  when  the  scrofulous  condition  has  been  partially 
relieved  or  cured. 

Treatment. — Prophylactic  treatment  should  be  given  in  all  cases 
in  which  it  is  possible.  Prophylaxis  consists  in  good  hygienic  con- 
ditions, with  the  various  factors  which  are  comprised  in  the  full 
meaning  of  this  term.  If  possible,  this  should  be  carried  to  the 
point  of  leading  an  outdoor,  country  life,  with  physical  training 
directed  to  the  development  of  the  entire  body.  The  simple  bitters 
are  useful,  and  the  following  prescription,  which  the  writer  has 
used  for  many  years,  includes  a  nerve-tonic  also,  and  is  as  follows : 
]^ — Tinct.  nucis  vomicae,  3iv; 

Tinct.  gentianse  comp.,  oiv.     M. 

Sig. — A  half-teaspoonful  in  a  little  water  before  meals. 

Cod-liver  oil  is  also  a  useful  agent,  and  may  be  given  in  con- 
junction with  the  lacto-phosphate  of  lime.  In  some  cases  with 
anemia  the  syrup  of  the  iodid  of  iron  and  manganese  is  efficient. 


CHAPTER    XVI. 
CHANCROID,  OR  SOFT  CHANCRE. 

Synonyms. — Non-infecting  chancre;  Chancre  mou,  Chancrelle 
(Fr.);  Chancre  (Germ.). 

Definition. — A  local  contagious  ulcer  (usually  of  the  genitals) 
of  high  inflammatory  grade  and  very  destructive.  It  is  entirely 
distinct  from  syphilis  as  a  disease.  Its  effects  do  not  invade  the 
entire  system;  it  may  be  inoculated  into  many  different  parts  of  the 
body,  and  in  each  case  a  soft  chancre  would  be  the  result;  this  is 
not  the  case  with  syphilis. 


SYPHILIS.  95 

Etiology. — The  usual  mode  of  conveyance  is  by  actual  contact 
in  the  act  of  coition,  by  which  means  the  pus  is  conveyed.  The 
disease  may  also  be  transmitted  by  means  of  the  fingers,  towels,  or 
instruments. 

Clinical  History. — These  ulcers  have  but  a  short  period  of  incu- 
bation, appearing  in  a  few  days  after  inoculation.  The  first  appear- 
ance upon  mucous  membranes  is  as  a  minute  yellow  spot,  sur- 
rounded by  a  bright  red  area.  This  yellow  spot  grows  larger, 
forming  a  pustule,  the  superficial  part  of  which  comes  away,  leav- 
ing an  ulcer  of  irregular  shape.  The  edges  are  sharply  cut  and 
abrupt,  being  somewhat  undermined.  The  bottom  of  the  ulcer  is 
uneven  and  covered  with  Hght  yellow  pus. 


CHAPTER    XVII, 
SYPHILIS.^^ 


Defiiiition. — A  chronic  infectious  disease,  first  manifested  in  a 
local  lesion,  afterward  appearing  in  every  part  of  the  organism. 

Nature  and  Course  of  the  Disease. — A  certain  point  in  the  body 
is  infected  with  the  syphilitic  virus,  and  after  a  period  of  invasion 
lasting  from  ten  days  to  two  months  a  chancre  is  sure  to  appear  at 
the  exact  point  of  infection.  This  so-called  "hard  chancre,"  or 
primary  sore,  marks  the  beginning  of  the  second  period  of  incuba- 
tion, during  which  time  the  entire  system  is  becoming  infected. 
Usually  within  ten  days  after  the  appearance  of  the  chancre  the 
lymphatic  glands  in  the  immediate  neighborhood  begin  to  enlarge, 
and  become  indurated,  forming  what  is  known  as  the  syphilitic 
bubo. 

At  the  end  of  the  second  period  of  incubation  the  entire  system 
has  become  infected;  this  usually  occurs  within  three  months  from 
the   appearance    of   the    chancre,    and   is    manifested    by    general 

*  Syphilis,  in  its  history,  evolution,  and  cotirse,  involving  as  it  does 
every  organ  and  tissue  of  the  body,  and  expressed  by  such  a  variety  of 
symptoms,  would  seem  out  of  place  in  this  work  if  discussed  in  detail, 
therefore  only  a  general  idea  of  the  disease  will  be  given,  with  especial  con- 
sideration of  its  infectious  nature  and  the  importance  of  preventing  the 
infection  of  dental  operators  and  their  patients. 


96  THE    PRACTICE    OF    DENTAL    MEDICINE. 

malaise,  headache,  and  pains  in  various  parts  of  the  body.  There 
is  also  an  eruption  of  papules  or  vesicles  upon  the  skin,  which  upon 
breaking  down  form  pustules;  these  become  dry,  but  a  progressive 
ulceration  is  going  on  beneath  the  scab. 

The  secondary  stage  of  syphilis  usually  lasts  from  a  year  and  a 
half  to  two  years,  when,  if  treatment  has  been  neglected,  the  so- 
called  tertiary  symptoms  appear,  which  simply  mark  a  further  stage 
in  the  progress  of  the  disease.  These  lesions  are,  as  a  rule,  more 
localized  but  of  a  deeper  and  more  serious  nature,  affecting  the 
internal  organs  and  bones.  It  is  slow  in  progress,  usually,  but 
often  very  destructive. 

Etiology.  Modes  of  Infection. — Infection  may  take  place  in 
three  ways:  ist.  By  actual  contact.  2d.  By  mediate  infection. 
3d.     By  hereditary  transmission. 

Infection  by  the  first  method  is  by  far  the  most  common,  the 
syphihtic  secretions  being  conveyed  by  personal  contact  to  an 
abraded  surface,  by  which  they  are  absorbed. 

By  the  second  method  infection  is  produced  by  means  of  instru- 
ments or  other  articles  which  have  on  them  some  of  the  syphilitic 
virus,  which  is  thus  brought  in  contact  with  some  abraded  surface 
of  the  body.  As  vehicles  for  transmitting  syphilis  in  this  way,  we 
may  mention  dental  and  surgical  instruments,  and  such  articles  as 
pipes,  cigars,  drinking-vessels,  knives,  spoons,  razors,  towels, 
sponges,  children's  toys,  candies,  etc. 

The  third  method,  by  hereditary  transmission,  indicates  a  con- 
veyance of  the  effects  of  syphilis  from  parents  to  offspring. 

Manifestations  of  Syphilis  within  the  Oral  Cavity. — The  initial 
lesion  of  syphilis  often  occurs  on  the  lips,  usually  at  the  site  of  a 
fissure.  In  point  of  frequency  the  tongue  is  next  attacked,  then 
the  gums  and  tonsils.  A  chancre  on  the  lip  (see  Plate  II.)  has  been 
mistaken  for  cancer,  but  cancer  is  painful,  more  irregular  in  out- 
line, occurs  nearly  always  on  the  lower  lip,  and  lacks  the  ivory 
hardness  of  a  syphilitic  chancre.  It  also  resists  treatment,  which 
is  not  usually  the  case  in  syphilis.  A  chancre  on  the  tongue 
appears  flat,  slightly  raised,  smooth,  and  red;  its  indurated  edges 
are  sharply  defined. 

In  the  secondary  stage,  gummatous  tumors  may  form  on  the 
lips  and  on  nearly  every  part  of  the  tongue,  being  common  on  its 
sides  and  base.  The  soft  palate  and  nasal  cavities  may  also  be 
involved.     Wherever  these  tumors  exist  the  appearance  is  char- 


PLATE    1  i. 


SYPHILIS.  97 

acteristic;  they  begin  as  a  small  round  tumor,  which  increases  in 
size  but  may  ulcerate  at  any  time,  causing  gieat  destruction  of  tis- 
sue. There  is  generally  no  pain  connected  with  the  development 
of  these  tumors,  but  there  may  be  seen  a  surrounding  redness  and 
induration.  If  the  induration  be  absent,  or  slight,  it  should  be 
remembered  that  this  deposit  of  tissue  constituting  the  hard  and 
firm  condition  surrounding  these  tumors  is  formed  in  a  gradual 
manner,  and  that  it  may  be  in  the  first  stages  when  the  examination 
is  made. 

In  the  tertiary  period  the  bones  of  the  jaws  may  become 
necrosed,  causing  much  destruction  and  inflammation,  loosening 
and  loss  of  teeth,  etc. 

Diagnosis. — Many  of  these  syphilitic  conditions  may  be  con- 
founded with  various  forms  of  pyorrhea,  but  by  attention  to  the 
description  of  the  lesions,  the  history,  and  the  results  of  treatment 
a  diagnosis  may  be  formed.  It  should  be  remembered  that  the  soft 
chancre  is  rarely  found  in  the  mouth,  and  that  it  presents  no  in- 
durated circumference.  Epithelioma  or  other  cancerous  lesions 
are  attended  with  more  or  less  pain,  and  other  skin  lesions  are  not 
usually  found. 

Aphthous  patches  may  resemble  small  ulcerated  gummata,  but 
the  absence  of  induration  and  of  other  lesions,  with  the  temporary 
character  of  aphthae,  should  determine  the  diagnosis. 

Effect  of  Syphilis  upon  the  Teeth. — Syphilis,  like  other  infectious 
diseases,  interferes  with  nutrition,  and  in  many  cases  may  arrest 
development,  which  is  later  shown  in  pits,  notches,  and  irregular 
formations  of  the  teeth,  but  it  does  not  appear  that  any  type  of 
defect  in  the  teeth  can  at  the  present  time  be  exclusively  connected 
with  a  syphilitic  cause.  It  is  well  known  that  the  Hutchinson  con- 
dition (a  crescent-shaped  notch  in  the  permanent  incisors)  and 
other  deformities  may  be  seen  in  patients  who  have  never  had 
syphilis  either  primary  or  inherited.  On  the  other  hand,  S3^philitic 
patients  often  present  a  well-formed  set  of  natural  teeth. 

Treatment. — The  medical  treatment  consists  mainly  in  the 
administration,  during  the  earlier  or  secondary  stage,  of  mercury 
in  some  form;  while  in  the  tertiary  stage  potassium  iodid  is  more 
plainly  indicated.  These  remedies  are  specific,  and  their  effect, 
when  intelligently  used,  is  remarkable.  Sometimes  mercury  and 
potassium  iodid  are  combined  with  advantage.  Cleanliness  of  the 
paits,  with  antiseptic  washes  and  other  hygienic  means,  are  neces- 
sary. 


98  THE    PRACTICE    OF    DENTAL    MEDICINE. 

CHAPTER    XVIII. 

RHEUMATISM. 
ACUTE  RHEUMATISM. 

Synonyms. — Rheumatic  fever;  Acute  articular  rheumatism. 

Eefinition. — A  disease  affecting  the  entire  human  system,  char- 
acterized by  fever  and  inflammation  of  the  joints,  with  a  tendency 
to  inflammation  of  the  scrolls  covering  and  lining  of  the  heart. 

Etiology. — This  disease  may  occur  at  all  seasons  of  the  year, 
although  it  appears  to  be  more  prevalent  in  temperate  climates 
than  in  the  polar  regions.  It  may  also  occur  at  any  age,  although 
the  largest  number  of  cases  occur  between  fifteen  and  twenty-five 
years  of  age.  A. moist  and  damp  condition  of  the  atmosphere  is 
supposed  to  invite  an  attack,  and  yet  the  disease  has  been  very 
prevalent  in  climates  which  are  remarkably  dry.  There  is  no 
doubt  that  a  predisposition  to  rheumatism  is  inherited.  Exposure 
to  cold  and  dampness,  especially  when  the  body  is  heated  and  per- 
spiring, will  probably  excite  an  attack  in  the  predisposed. 

Symptoms. — An  acute  attack  begins  usually  with  some  mus- 
cular soreness,  accompanied  by  darting  pains  of  a  neuralgic  char- 
acter; also  pain  on  movement  of  certain  joints.  As  the  attack 
progresses  the  digestive  organs  indicate  an  inflammatory  action, 
as  seen  in  the  coated  tongue,  thirst,  lack  of  appetite,  constipation, 
etc.  Later  the  affected  joints  are  swollen,  accompanied  by  the 
other  symptoms  of  inflammation. 

The  slightest  movement  of  the  joints  causes  extreme  pain. 
The  affection  of  the  joint,  or  joints,  may  travel  to  other  parts,  thus 
appearing  successively  in  different  joints  of  the  body.  This  ten- 
dency to  change  from  one  joint  to  another  is  characteristic  of  rheu- 
matism. The  temperature  in  these  acute  cases  usually  rises  to 
103°  or  104°  F.,  rising  and  falling  with  no  regulaiity,  during  the 
disease.  In  very  severe  cases,  of  course,  all  these  symptoms  are 
exaggerated.  It  is  also  noticed  that  there  is  a  free  perspiration 
having  a  strong  acid  odor. 

CHRONIC  RHEUMATISM. 

Definition. — This  term  simply  indicates  a  prolongation  of  the 
acute  form  of  rheumatism  with  modified  symptoms  according  to 
the  severity  of  the  disease. 


RHEUMATISM.  99 

Symptoms  and  Diagnosis. — In  the  chronic  form  of  this  disease 
the  joints,  principally,  are  affected;  they  are  usually  more  or  less 
swollen,  and  their  movements  are  restricted.  Atmospheric 
changes,  especially  those  marked  by  a  falling  of  the  barometer 
indicative  of  an  impending  storm,  always  affect  the  predisposed. 
A  stiffness  and  soreness  of  the  joints  is  noticed,  more  particularly 
in  the  morning,  as  exercise  renders  them  supple  and  less  likely  to 
give  pain  on  motion.  Often  rhe  disease  is  present  when  the  symp- 
toms are  not  sufficiently  pronounced  to  indicate  it  at  first  sight. 
In  fact,  the  patient  may  not  know  that  he  is  affected  with  such  a 
disease.  In  these  cases,  in  which  the  ordinary  rheumatic  symp- 
toms are  absent,  if  the  patient  is  asked  if  he  has  neuralgia  the 
answer  will  usually  be  in  the  affirmative. 

Erosion  of  the  teeth,  and  some  of  the  forms  of  pyorrhea  alveo- 
laris,  are  regarded  by  many  as  true  expressions  of  a  rheumatic 
diathesis.  For  many  years  the  endeavor  to  trace  the  connection 
of  these  symptoms,  as  shown  in  the  teeth  and  gums,  with  some 
form  of  rheumatism  has  resulted  in  finding,  in  every  marked  case 
of  so-called  pyorrhea,  certain  symptoms,  more  or  less  marked,  of  a 
rheumatic  diathesis. 

Treatment. *^ — Hygiene  is  of  the  first  importance.  The  finest 
wool  underclothing  should  be  worn  the  year  round.  Avoid 
exposure  to  cold  and  dampness.  Avoid  all  starchy  and  saccharine 
foods,  as  well  as  an  excess  of  salt.  Also  avoid  malt  liquors,  wines, 
and  coffee.  As  suitable  foods  the  following  may  be  named:  Beef, 
and  nearly  all  kinds  of  fish.  Green  vegetables,  beans,  peas,  etc. 
Brown  breads.     Black  tea.     Acid  fruits.     Milk  with  lime-water. 

Exercise  in  the  open  air,  sufficiently  vigorous  to  cause  profuse 
perspiration,  and  followed  by  shower-baths  with  brisk  rubbing, 
is  of  excellent  service.  Pure  water  should  be  taken  abundantly, 
from  three  to  five  glasses  before  breakfast  as  a  rule,  and  at  other 
times  during  the  day.  Good  results  may  be  obtained  from  Sara- 
toga Vichy  water,  a  pint  taken  with  each  meal.  One  of  the  oldest 
and  most  reliable  remedies  for  this  disease  is  the  salicylate  of 
sodium.  It  should  be  given  persistently  in  full  doses  unless  the 
stomach  rebels.  If  this  should  occur  the  salicylate  of  quinin  may 
be   tried.      Other    remedies    are   potassium    iodid,    cod-liver    oil, 

*  The  brief  outline  of  treatment  here  indicated  is  given  with  the  object 
•of  assisting-  in  the  treatment  of  pyorrhea  alveolaris. 


lOO  THE    PRACTICE    OF    DENTAL    MEDICINE. 

arsenic,  iodid  of  iron,  and  quinin.  The  different  preparations  of 
lithium,  according  to  Bartholow,  are  efficacious.  Tablets  of 
lithium  bitartrate  (tartarlithine),  suggested  by  Dr.  E.  C.  Kirk,  have 
been  advocated  and  have  produced  good  results.  One  of  these 
tablets  dissolved  in  one-half  glass  of  hot  water  should  be  taken 
half  an  hour  before  each  meal;  at  night  two  tablets  may  be  taken 
before  retiring.  The  oil  of  wintergreen  is  an  efficient  remedy; 
from  five  to  fifteen  drops  may  be  taken  on  sugar  or  in  an  emulsion. 
The  following  prescription  containing  this  oil  may  be  found  useful : 


M. 


15 — O.lei  gaultherise, 

5j; 

Acidi  salicylici, 

3iv 

Sodii  biboratis, 

5j; 

Syrupi  picis  liquidas, 

3ij; 

Aquas  anisi. 

oij. 

Sig.- 

—Two  teaspoonfuls  every  four  hours. 

CHAPTER    XIX. 

DYSPEPSIA. 

Dyspepsia  is  a  term  in  general  use  by  the  laity,  which  may 
indicate  a  simple  disturbance  in  the  function  of  digestion  or  any 
intermediate  condition  between  this  and  the  more  severe  cases  of 
gastric  disturbance.  Furthermore,  this  term  has  been  constantly 
applied  to  chronic  inflammation  of  the  stomach,  or  chronic  gas- 
tritis. 

Strictly  speaking,  acute  gastritis  is  almost  unknown,  for  an 
acute  destructive  inflammation  of  the  stomach  is  limited  nearly 
always  to  those  cases  resulting  from  toxic  causes.  But  the  object 
heie  is  to  consider  those  less  severe  forms  of  irritation  of  the 
stomach  which  are  of  frequent  occurrence.  It  is  in  this  broader 
sense,  therefore,  that  this  term  will  now  be  regarded. 

ACUTE  GASTRITIS. 

Etiology. — An  acute  gastritis,  so  called,  is  usually  brought 
about  by  sudden  atmospheric  changes;  errors  in  diet;  excessive 
eating;  or  the  abuse  of  ices,  condiments,  and  alcoholic  drinks. 
The  occupation  and  habits  of  life  have  a  predisposing  influence. 

A  very  important  factor  in  the  production  of  gastric  irritation 


CHROXIC    GASTRITIS.  lOI 

is  insufficient  mastication,  due  to  carious  teeth  or  the  absence  of 
teeth.  This  cause  alone  may  produce  a  mild  form  of  gastritis, 
during  which  acute  attacks  may  occur  from  time  to  time. 

The  nose,  naso-pharynx,  and  mouth  constitute  a  very  citadel 
for  the  habitation  and  propagation  of  various  forms  of  bacteria. 
Respiration  and  the  act  of  swallowing  serve  to  convey  these  organ- 
isms to  distant  parts  of  the  body,  and  it  is  now  believed  that  an 
unhygienic  nasal  and  oral  condition  is  often  a  prominent  factor  in 
the  causation  of  diseases  in  other  and  remote  parts. 

The  stomach,  being  the  direct  receptacle  for  all  substances 
swallowed,  is  especially  liable  to  inflammatory  attacks,  due  to 
organisms  which  have  been  carried  there  by  the  act  of  swallowing. 
The  nasal  secretions,  containing  bacteria,  pass  into  the  pharynx 
and  are  swallowed.  The  crypts  of  the  faucial  tonsils  often  contain 
offensive  secretions  containing  great  numbers  of  bacteria,  and 
these  are  also  swallowed.  Teeth  that  have  large  carious  cavities 
serve  to  collect  and  propagate  micro-organisms  which  get  into  the 
throat  during  mastication  and  go  into  the  stomach. 

Crevices  between  the  teeth,  unclean  regulating  appliances,  im- 
properly constructed  bridges,  the  pockets  of  pyorrhea,  and  ulcer- 
ated parts  of  the  mouth,  all  contribute  to  send  down  into  the 
stomach  such  numbers  of  micro-organisms  that  it  is  no  wonder 
that  the  stomach  rebels, — indeed,  the  wonder  is  that  it  is  not 
oftener  afTected. 

Symptoms. — Appetite  depraved  or  wanting,  inability  to  sleep, 
headache,  occasional  dizziness,  and  pain  over  the  stomach  are 
among  the  symptoms.  The  tongue  is  covered  with  a  white  or 
yellowish-white  coat,  and  often  enlarged;  the  sense  of  taste  is  per- 
verted, and  in  the  morning  the  mouth  is  pasty  and  covered  with  a 
bitter-tasting  mucus.  Nausea  exists  in  varying  degrees,  accom- 
panied by  vomiting,  especially  if  the  attack  is  caused  by  indiges- 
tion. The  breath  is  fetid  and  there  are  also  eructations  of  gas,  the 
result  of  decomposition. 

CHRONIC  GASTRITIS. 

Etiology. — This  differs  from  the  acute  form  in  that  heredity 
exercises  an  important  influence;  otherwise  the  causes  are  much 
the  same.  Indeed,  the  majority  of  cases  of  chronic  gastritis  are 
but  a  continuation  of  the  acute  form,  showing,  however,  a  marked 
abatement  of  all  the  symptoms. 


I02  THE    PRACTICE    OF    DENTAL   MEDICINE. 

Symptoms. — In  this  form,  known  as  dyspepsia,  the  symptoms 
are  much  less  severe.  The  patient  suffers  especially  after  taking 
food,  although  he  is  rarely  free  from  some  disagreeable  sensation 
about  his  stomach.  The  gases  which  are  formed  as  a  result  of 
indigestion  distend  the  stomach,  causing  much  distress.  Other 
organs  are  often  displaced  by  this  means,  and  another  set  of  symp- 
toms appears. 

Effect  upon  the  Teeth. — It  will  be  seen  that  a  collection  of 
sticky  mucus  about  the  teeth,  which  is  readily  decomposed,  not 
only  may  act  injuriously  upon  any  defect  in  the  teeth,  but  favors 
decay  by  interfering  with  the  proper  cleansing  of  them.  Besides 
this,  during  the  existence  of  these  stomach  diseases  there  are  fre- 
quent eructations  of  acrid  vapor,  as  well  as  the  acid  contents  of  the 
stomach  and  vomited  matters,  which  cannot  fail  to  act  injuriously 
upon  the  teeth.  Moreover,  the  dyspeptic  is  limited  to  soft  liquid 
foods,  requiring  little  or  no  mastication;  this  gives  the  teeth  no 
exercise,  while  the  lack  of  friction  favors  uncleanliness  and  a 
gradual  weakening  of  the  teeth  with  their  surrounding  tissues. 
The  dentist  has  often  observed  the  superior  condition  of  teeth  upon 
the  side  of  the  mouth  where  mastication  chiefly  occurs.  A  still 
more  important  consideration  is  the  fact  that  a  person  suffering 
from  dyspepsia  does  not  receive  into  his  system  the  proper 
elements  which  go  to  support  the  nutrition  of  the  teeth.  Further- 
more, the  condition  of  the  digestive  apparatus  is  such  that  what- 
ever is  received  as  food  does  not  really  feed  the  system  because 
the  materials  are  not  assimilated. 

Treatment. — A  very  brief  outline  of  the  treatment  of  chronic 
gastritis  may  be  indicated  as  follows:  Regulate  the  diet  by  omit- 
ting the  articles  known  to  disagree,  avoiding  sweet  and  fatty  sub- 
stances, and  instead  of  these  taking  vegetables,  such  as  lettuce, 
spinach,  celery,  etc.  The  writer  has  had  marked  success  in  his 
own  practice  by  adopting  the  "skimmed-milk  cure"  advised  by 
Bartholow.  This  treatment  consists  in  the  use  of  skimmed  milk 
alone  as  a  diet  for  several  weeks,  or  even  months,  if  necessary, 
when  some  additions  to  the  diet  may  be  made,  such  as  fresh  milk 
with  lime-water.  The  diet  may  be  gradually  varied  by  using  stale 
bread,  followed  by  rice,  and  so  on,  as  the  patient  can  bear  it.  Fow- 
ler's solution,  one  or  two  drops  three  times  a  day  before  meals,  is 
an  efficient  remedy.  The  simple  bitters  should  be  used  with  cau- 
tion, being  more  especially  adapted  to  atonic  dyspepsia  and  very 


TETANUS.  103 

mild  chronic  cases.  Marked  results  have  followed  the  substitution 
of  artificial  teeth  for  those  which  had  been  lost,  also  the  filling  of 
carious  teeth  so  that  mastication  could  be  properly  performed. 
This  is  a  matter  of  such  importance  that  it  should  not  be  over- 
looked, as  it  has  been  in  the  past.  Cases  of  dyspepsia  require 
special  attention  to  the  hygiene  of  the  mouth.  Alkaline  and  anti- 
septic washes  should  be  prescribed,  and  the  dentist  should  take 
particular  interest  to  see  that  his  directions  are  faithfully  and 
intelligently  carried  out. 


CHAPTER    XX, 

TETANUS. 


Definition. — Tetanus  comes  from  a  Greek  word  {ni-^w)  mean- 
ing 'T  stretch."  It  is  an  acute  disease  in  which  the  voluntary 
muscles  contract  in  paroxysms,  due  to  an  excessive  functional  de- 
rangement of  the  spinal  cord. 

Varieties. — Acute  and  Chronic. — While  tetanus  is  designated  as 
an  acute  affection,  it  often  assumes  the  chronic  form,  in  which 
there  is  a  longer  time  between  the  injury  and  the  appearance  of 
the  symptoms,  and  which  is  marked  by  periods  of  rest,  affording  an 
opportunity  for  the  patient  to  recuperate,  thus  giving  hope  of  re- 
covery. 

Tetanus  Hydrophobicus. — Chiefly  confined  to  the  head,  and  due 
to  infected  wounds  in  the  mouth,  face,  or  any  other  part  of  the 
head. 

Trismus  Xasccntiuui. — Tetanus  occurring  in  the  infant  within 
two  weeks  from  birth,  due  probably  to  infection  of  the  umbilical 
cord. 

Puerperal  Tetanus. — This  variety  occurs  after  abortion  or  pre- 
mature labor,  and  while  it  has  been  observed  to  occur  after  adhe- 
sion of  the  placenta  or  the  use  of  the  forceps,  there  is  no  reason  for 
believing  that  there  is  in  these  cases  any  special  cause  other  than 
the  bacillus  at  work.'^' 

Etiology. — Tetanus  is  a  disease  that  interests  the  dentist  be- 
cause it  affects  the  jaw,  and  because  dental  diseases,  as  alveolar 

*  See  "Diagnosis''  for  other  varieties  and  simulated  conditions. 


I04  THE    PRACTICE    OF    DENTAL   MEDICINE. 

abscess,  also  tooth-extraction,  produce  a  solution  of  the  con- 
tinuity of  tissue,  which  may  become  infected  with  the  bacillus 
tetani.* 

Tetanus  has  been  popularly  supposed  to  be  due  to  some  wound 
in  the  body,  especially  a  punctured  one;  to  exposure  to  heat,  or 
to  cold  and  damp  following  vigorous  exercise  with  perspiration; 
also  that  the  cicatrix  in  forming  may  compress  a  nerve  or  nerves 
and  thus  bring  on  the  paroxysm.  The  disease  was  also  supposed 
to  occur  idiopathically,  and  to  be  found  more  frequently  in  the 
negro  than  in  other  races.  All  the  above  theories,  however,  have 
been  overturned  by  the  discovery  of  the  bacillus  tetani  by  Nicolaier 
of  Gottingen,  in  1885,  followed  by  the  experiments  of  Kitasato  in 
1889,  who  first  made  a  pure  culture  of  this  microbe.  Later  experi- 
mentation upon  animals  has  shown  that  the  tetanus  bacillus  is  the 
cause  of  so-called  "traumatic"  tetanus,  and  it  is  likely  to  prove  true 
that  all  other  varieties  of  genuine  tetanus  may  be  traced  to  the 
same  germ  origin;  for  instance,  we  may  well  suppose  that  in  the 
so-called  "idiopathic"  forms  there  must  have  been  some  slight 
lesion  of  the  skin  or  mucous  membrane  through  which  tetanus 
bacilli  entered,  and  the  abrasion  or  wound  healed  quickly  (the 
tetanus  bacillus  having  no  pyogenic  properties),  thus  removing  all 
outward  manifestation  of  the  cause. 

In  cases  of  so-called  "scar"  tetanus  the  symptoms  of  tetanus 
were  probably  produced  by  reflex  action  due  to  the  peripheral 
injury  to  the  nerves  caused  by  the  impingement  of  the  scar-tissue; 
in  such  cases,  therefore,  we  must  assume  that  the  diagnosis  was  at 
fault. 

The  existence  of  the  tetanus  bacillus  is  widespread,  the  micro- 
organism being  found  in  garden  earth,  in  the  dust  of  streets,  in 
stables,  and  in  putrid  liquids,  but  it  is  markedly  anaerobic,  being 
destroyed  by  the  action  of  oxygen;  thus  it  is  that  many  superficial 
wounds  exposed  to  the  oxygen  of  the  air  do  not  admit  of  the  multi- 
plication of  bacilli  and  the  production  of  toxins;  and  this  accounts 
to  a  great  extent  for  the  rarity  of  tetanus  as  a  disease.  In  punc- 
tured wounds  it  is  quite  different;  the  nail,  splinter  of  wood,  or 
bullet,  carries  the  bacillus  deep  into  the  tissues,  where  it  is  unaf- 
fected by  the  oxygen  of  the  air,  and  finds  a  better  soil  for  its 
growth.  The  bacillus,  however,  does  not  directly  cause  the  symp- 
toms of  tetanus,  but  indirectly  by  means  of  a  poison  which  is  gen- 

*  See  cases  in  "American  System  of  Dentistry,"  vol.  iii.  p.  489. 


TETANUS.  105 

erated  at  the  seat  of  the  wound.  This  may  be  shown  by  taking 
the  fihrate  of  a  tetanus  bouillon  culture  which  contains  no  bacilli, 
and  injecting  it  into  a  white  mouse,  and  the  same  symptoms  may 
be  produced  as  those  which  are  the  result  of  an  injection  of  the 
bacillus  itself. 

Symptoms. — The  disease  begins  with  a  feeling  of  lassitude  and 
weakness,  often  followed  by  sore  throat  and  stiffness  of  the  neck, 
and  an  inability  to  open  the  mouth  widely.  This  becomes  notice- 
able at  meal-times,  when  difficulty  is  experienced  in  masticating 
and  food  is  not  taken,  more  on  account  of  this  trouble  than  from 
want  of  appetite.  The  illness  increases  rapidly,  and  in  twenty- 
four  hours  the  symptoms  may  become  alarming.  The  teeth  are 
clenched,  the  countenance  gives  the  appearance  of  age  and  exhaus- 
tion, and  the  voice  is  changed  to  a  feeble,  inarticulate  sound.  At 
this  time,  while  the  patient  may  have  an  appetite,  it  is  almost 
impossible  for  him  to  swallow  food,  and  every  attempt  brings  on 
a  spasm  of  the  throat.  The  muscles  of  the  neck  and  back  become 
stiff  and  hard,  and  any  slight  shock,  such  as  the  slamming  of  a 
door,  may  bring  on  a  spasm,  the  patient  being  in  a  state  of  opisthot- 
onos. This  spasm  may  last  for  several  minutes ;  the  skin  becomes 
dusky  and  covered  with  perspiration,  and  the  facial  expression  is 
horrible.  The  term  "risus  sardonicus"  conveys  an  idea  of  the 
frightful  appearance  of  the  patient  under  these  circumstances. 
At  this  stage  of  the  disease,  it  is  wellnigh  impossible  to  take  food, 
either  by  the  mouth  or  by  enemata.  The  tongue  and  cheeks  are 
bitten,  and  frothy  saliva  tinged  with  blood  comes  from  the  mouth; 
the  patient  is  unable  to  sleep,  and  the  pains,  when  they  come  on, 
are  most  distressing. 

As  the  spasms  increase  in  frequency  the  pulse  becomes  quick, 
weak,  and  irregular,  while  nearly  all  the  muscles  of  the  body  are 
in  a  state  of  rigidity.  This  condition  directly  affects  the  respira- 
tory organs  and  interferes  with  breathing.  During  this  time  in 
which  the  patient  is  sinking,  dying  from  pain,  starvation,  and 
inability  to  breathe,  the  mind  remains  perfectly  clear. 

Course,  Duration,  etc. — Tetanus  may  run  an  acute  course,  ter- 
minating in  death  in  a  few^  days,  or  it  may  assume  a  chronic  type, 
in  which  the  intervals  between  the  spasms  are  longer  and  the  pain 
is  not  so  severe.  Sleep  and  food  may  be  taken  during  these  inter- 
vals and  the  prognosis  is  largely  governed  by  the  length  of  time 
between  the  spasms  as  well  as  by  their  severity. 


lo6  .THE    PRACTICE    OF    DENTAL    MEDICINE. 

Diagnosis. — In  the  diagnosis  of  this  disease,  the  symptoms 
should  be  kept  well  in  mind^  so  as  to  distinguish  it  from  other  dis- 
eases having  some  of  the  symptoms  in  common. 

Stiffness  of  tJic  jazu  due  to  inflammatory  conditions  within  the 
mouth,  such  as  alveolar  abscess  or  inflammation  about  the  tem- 
poro-maxillary  articulation,  may  be  distinguished  from  tetanus  by 
the  absence  of  spasm  and  by  an  examination  which  will  reveal  the 
cause  of  the  existing  condition. 

The  writer  once  had  a  case  of  supposed  tetanus  brought  to  him 
for  diagnosis  and  treatment.  The  upper  and  lower  teeth  could 
be  separated  only  half  an  inch;  there  was  severe  pain,  some  swell- 
ing of  the  face,  and  general  bodily  weakness.  Tetanus  was  ruled 
out  on  account  of  the  time  which  had  elapsed  during  the  develop- 
ment of  the  symptoms,  the  absence  of  spasm,  muscular  rigidity, 
etc.,  and  a  diagnosis  of  actinomycosis  was  made. 

Hysterical  contraction  of  the  masseter  muscles  and  cases  of 
severe  reflex  irritation  may  usually  be  recognized  by  studying  the 
history  of  the  case. 

''Tetany,"  a  rare  disease  in  America,  is  distinguished  from 
tetanus  by  the  fact  that  pressure  on  the  nerve-trunk  leading  to  the 
affected  muscles  always  brings  on  a  spasm,  and  by  the  knowledge 
that  trismus  never  occurs  in  tetany. 

In  strychnin  poisoning  the  symptoms  come  on  and  terminate 
suddenly,  and  there  is  not  necessarily  a  wound  or  other  similar 
cause  for  the  attack. 

There  are  tonic  spasms  of  the  muscles  in  spinal  meningitis,  but 
they  are  not  paroxysmal  and  there  are  no  periods  of  cessation  of 
the  morbid  process.  In  tetanus  the  slightest  causes  produce 
reflex  spasms;  this  is  not  the  case  in  spinal  meningitis. 

Hydrophobia  has  some  symptoms  similar  to  those  of  tetanus, 
but  the  difficulty  in  swallowing  water  and  the  hawking  noise  made 
in  the  effort  to  expel  the  viscid  mucus  from  the  throat  in  h3'dro- 
phobia  are  not  found  in  tetanus. 

Prognosis. — The  prognosis  depends  mainly  upon  the  rapidity 
with  which  the  case  develops,  and  the  length  of  time  for  rest  and 
sleep  between  the  spasms;  a  favorable  outlook  being  promised 
when  the  case  is  late  in  developing,  and  when  there  are  long 
periods  in  which  there  is  a  cessation  of  marked  symptoms. 

Treatment. — On  general  principles,  it  is  important  that  dirt 
and  poisonous  substances  should  be  removed  as  thoroughly  as 


TETANUS.  107 

possible  from  all  wounds;  but  it  is  especially  so  if  the  wound  be 
a  punctured  one  into  which  dirt  containing  the  bacillus  tetani  has 
probably  been  carried.  Under  these  circumstances  it  is  important 
that  a  bacteriological  examination  be  made,  taking  the  material 
for  e::amination  from  the  agent  making  the  wound  or  from  the 
wound  itself.  If  some  of  the  suspected  material  be  injected  under 
the  skin  of  a  mouse,  and  the  animal  dies  with  the  symptoms  of 
tetanus,  the  patient  should  receive  proper  serum  treatment  at  once. 

Experiments  upon  animals  have  demonstrated  that  death  may 
be  prevented  by  the  use  of  antitoxin  when  a  toxic  dose  has  been 
administered,  but  on  account  of  the  rarity  of  the  disease  and  con- 
sequent lack  of  statistical  evidence,  definite  conclusions  have  not 
yet  been  reached  as  to  the  effect  in  the  treatment  of  tetanus  in  man 
when  the  symptoms  have  become  established.  There  is  every 
reason  to  believe,  however,  that  the  antitoxic  serum  (there  are 
several  preparations  in  the  market)  has  a  true  antidotal  power,  and 
that  its  influence  upon  the  disease  in  years  to  come  will  be  marked. 

To  briefly  summarize  the  important  points  to  be  remembered, 
we  may  say  that  it  is  fairly  well  established  that  the  antitoxin 
treatment  has  a  marked  prophylactic  influence;  that  the  bacteria 
develop  very  rapidly,  and  that  large  doses  must  be  administered 
in  proportion  as  the  disease  has  progressed. 

It  is  possible  that  the  antitoxin  does  not  act  upon  the  same 
tissues  as  the  toxin.  The  moment  this  poison  enters  the  blood  it 
begins  at  once  to  enter  into  combination  with  the  tissues,  after- 
wards acting  principally  upon  the  central  nervous  system.  It  has 
been  claimed  that  the  antitoxin  has  no  direct  influence  upon  these 
tissues,  and  if  this  is  true  it  explains  the  slight  effect  of  the  anti- 
toxin when  it  has  been  administered  after  the  symptoms  were  fully 
established. 

The  intracerebral  injection  of  antitoxin,  first  performed  by 
Ouenu  and  Chauffard,*  has  been  recently  practiced  by  Dr.  Ram- 
baud,  of  the  New  York  Pasteur  Institute.  This  was  the  eighth 
case  on  record,  and  the  first  in  which  the  operation  was  performed 
in  this  country;  it  was  followed  by  recovery.  The  operation  con- 
sists in  trephining  the  skull  on  each  side  opposite  the  fissure  of 
Rolando,  and  injecting  about  three  cubic  centimeters  of  the  anti- 
toxic fluid  into  the  brain. 

This  direct  application  of  the  remedy  into  the  tissues  where  the 

*  La  Pressc  Mcdicalc.  June  18,  1898. 


I08         f  THE    PRACTICE    OF    DENTAL    MEDICINE. 

toxins  of  tetanus  have  become  fixed  seems  to  have  a  more  potent 
effect  than  the  injection  of  antitoxin  into  other  parts  of  the  body; 
but  one  case  has  recently  come  to  the  knowledge  of  the  writer  in 
which  the  symptoms  of  tetanus  were  far  advanced,  and  the  injec- 
tion into  a  vein  of  a  pint  of  serum  daily  was  followed  by  recovery. 

The  general  treatment  should  consist  of  remedies  which  reduce 
the  reflex  irritability  of  the  spinal  cord,  as  potassium  bromid. 
Bartholow  advises  large  doses  of  this  remedy;  one  or  two  drams 
every  four  hours,  to  be  diminished  as  the  spasms  are  reduced. 
All  noises  and  other  causes  of  excitement  and  reflex  irritation 
should  be  prohibited. 

The  disease  is  one  of  great  depression,  and  the  spasms  and 
pain  exhaust  the  patient  rapidly;  therefore  warm  nourishing 
drinks,  and  wine  or  some  similar  stimulant,  should  be  adminis- 
tered. 

Ether  may  be  carefully  used  for  the  spasms  and  pain,  or  sub- 
cutaneous injections  of  morphin  may  accomplish  the  same  result; 
the  injections  being  used  only  in  sufficient  quantities  to  relieve  the 
local  irritation,  and  care  being  exercised  not  to  depress  the  general 
system.  Dr.  Joseph  Hartshorne  many  years  ago  called  attention 
to  the  ef^cacy  of  vigorous  counter-irritation  over  the  spine.  Rest, 
quiet,  and  warmth  are  indispensable. 


GINGIVITIS.  109 


LOCAL  DISEASES  AFFECTING  THE  SOFT  TISSUES 
OF  THE  MOUTH. 


CHAPTER    XXI. 

GINGIVITIS. 

Synonyms. — Inflammation  of  the  gums;  Spongy  gums;  Perio- 
dontitis ;  Ulitis. 

Definition. — An  inflammation  of  the  gums. 

Etiology. — The  most  common  local  causes  are  the  retention 
and  decomposition  of  food  particles  and  mucous  cells  at  the  gum 
margin;  the  careless  use  of  wood  toothpicks;  ligatures  accidentally 
left  under  the  gum;  various  wounds  to  the  gum  during  certain 
operations  on  the  teeth;  and  the  wearing  of  regulating  appliances 
not  admitting  of  thorough  cleansing.  Besides  the  above-named 
local  causes,  some  diseases  and  certain  drugs  when  taken  into  the 
system  find  local  expression  in  the  form  of  gingivitis.  Salter  has 
demonstrated  the  fact  that  when  potassium  iodid  has  been  taken 
internally  with  resulting  gingivitis,  the  cells  taken  from  the  gum 
margin  and  submitted  to  a  chemical  test  show  the  presence  of 
iodin.  Mercury  has  a  similar  effect.  Scurvy  is  a  systemic  disease 
having  a  local  manifestation  in  the  gums,  and  is  often  diagnosed 
as  gingivitis. 

Pathology  and  Symptoms. — Ordinarily  the  severity  of  the  local 
disease  is  not  sufficient  to  produce  constitutional  disturbances. 
The  gums  present  varying  degrees  of  redness,  tumefaction,  or 
swelling,  according  to  the  severity  of  the  case.  Fermenting  and 
corroding  substances  coming  in  contact  with  the  gum  often  cause 
it  to  be  denuded  of  its  epithelial  covering  and  to  present  a  "raw" 
surface,  which  bleeds  upon  the  slightest  touch,  and  is  painful 
during  mastication  or  upon  contact  with  irritating  substances  in 
food  or  drink.     In  severe  cases  there  is  fetor  of  the  breath. 

Prognosis. — The  prognosis  depends  upon  the  cause,  which,  if 
local,  can  often  be  easily  eradicated;  but  if  of  constitutional  origin 
it  may  present  some  difficulty. 

Diagnosis. — The  only  question  that  may  arise  in  regard  to  the 
diagnosis  is  this:  Have  we  under  consideration  a  simple  case  of 
gingivitis,  or  is  the  inflammation  present  merely  an  expression  or 


no  THE    PRACTICE    OF    DENTAL    MEDICINE. 

symptom  of  some  other  disease?  If  a  symptom  of  some  other  dis- 
ease, a  study  of  the  symptoms  of  those  diseases  which  are  charac- 
terized by  gingivitis  as  a  symptom  will  enable  one  to  form  a  correct 
diagnosis. 

Treatment. — Cleanliness  is  the  first  requisite,  for  retention  of 
decomposing  substances  in  contact  with  the  gums  is  usually  the 
only  and  sufficient  cause  for  the  continuance  of  the  disease.  After 
the  parts  are  cleansed,  an  astringent,  such  as  the  undiluted  tincture 
of  catechu,  applied  with  a  camel's-hair  brush,  is  sufficient  in  simple 
cases. 

If  the  inflammation  extends  over  a  considerable  surface,  and 
the  parts  are  sensitive  to  food  and  drink,  the  combination  of  the 
astringent  with  an  anesthetic  and  antiseptic  will  be  of  value. 

3J — Acidi  carbolici  (Calvert's  No.  i)  gtt.  xx; 
Olei  gaultheriae,  gtt.  ij ; 

Tinct.  catechu,  oiv.     M. 

Sig. — Apply  to  the  gums  by  means  of  a  camel's-hair  brush. 
The  local  irritation  may  be  acting  as  the  immediate  or  direct 
cause,  while  a  constitutional  taint  or  temporary  condition  of  the 
system  may  be  the  underlying  and  original  cause.  The  diagnosis 
and  treatment  of  these  constitutional  conditions  must  then  claim 
attention  in  the  further  treatment  of  the  case. 


CHAPTER    XXII. 
PYORRHEA  ALVEOLARIS.* 

One  form  of  this  disease  is  characterized  by  large  deposits  of 
calcium  phosphate  and  carbonate  around  the  teeth  at  the  gingival 
border. 

Synonyms  (1). — Riggs's  disease;  Tartar;  Calcic  inflammation; 
Salivary  calculus;  Ptyalogenic  calcic  pericementitis. 

Another  form  is  determined  by  a  thin,  hard,  black  deposit,  often 
far  up  toward  the  apex  of  the  root. 

Synonyms  (2). — Riggs's  disease;  Tartar;  Serumal  calculus; 
Sanguinary  calculus;  Hematogenic  calcic  pericementitis. 

*  This  term  has  been  made  to  include  a  variety  of  pathological  condi- 
tions of  the  gum  and  pericemental  membrane. 


PYORRHEA    AL\'EOLARIS.  Ill 

Etiology. — Opinions  regarding  the  etiology  of  this  disease  are 
divided  between  hereditary,  constitutional,  and  local  causes.  In 
the  consideration  of  causes,  it  is  especially  important  to  designate 
them  accurately  according  to  their  particular  relation  to  the  dis- 
ease. For  instance,  one  observer  speaks  of  this  as  a  cause,  and 
another  of  that,  without  designating  the  cause  as  immediate  or 
remote,  exciting  or  predisposing.  In  order  to  avoid  the  confusion 
which  must  result  from  this  practice,  let  us  insist  that  immediate, 
intermediate,  and  remote  causes  shall  be  designated  as  such. 

Calculary  deposits  are  inseparably  connected  with  nearly  all 
forms  of  pyorrhea,  and  while  these  formations  may  be  utilized  as 
symptoms,  and  properly  designated  as  such,  they  also  have  a  causal 
relation,  and  should  receive  some  consideration  at  this  point. 

While  it  is  true  that  hard  formations  may  occur  in  various 
parts  of  the  human  body,  the  immediate  causes  must  vary  with  the 
location  and  character  of  the  solution  from  which  the  deposit  is 
formed.  It  is  generally  supposed  that  the  deposits  which  are 
formed  in  cavities,  or  ducts,  are  simply  deposited  from  the  fluid 
which  has  held  them  in  solution,  while  those  which  occur  within 
the  substance  of  an  organ  or  tissue  are  regarded  as  products  of 
some  nutritive  irritation. 

The  fluid  which  exists  in  the  mouth  comes  mainly  from  three 
sets  of  glands.  That  from  the  parotid  contains  no  mucin,  but 
COo  and  calcium  bicarbonate  in  solution.  That  from  the  sub- 
maxillary gland  contains  mucin  and  calcium  carbonate,  which 
ma}^  be  precipitated.  The  secretion  of  the  sublingual  gland  con- 
tains still  more  mucin  and  is  markedly  alkaline. 

The  manner  in  which  the  salivar}^  calculus  is  formed  has  been 
the  subject  of  speculation  resulting  in  the  promulgation  of  various 
theories.  It  has  been  held  that  the  saliva,  holding  in  solution  cal- 
cium carbonates  and  phosphates,  enters  the  mouth  from  the 
salivary  ducts,  and  at  this  time  the  carbon  dioxid,  by  which  the 
solution  is  held,  escapes,  and  the  salts  above  mentioned  are  depos- 
ited. But  it  is  not  known  what  causes  the  escape  in  one  instance 
and  the  retention  and  perfect  solution  in  the  other.  The  opinion 
has  also  been  advanced  that  the  calcium  salts  are  merelv  suspended 
in  the  saliva,  and  that  they  are  deposited  when  the  conditions  for  it 
are  favorable. 

Prof.  H.  H.  iBurchard*  has  called  attention  to  the  fact  that 
*Deiital  Cosmos  for  November  iSqt. 


112  THE    PRACTICE    OF    DENTAL    MEDICINE. 

along  the  gingival  border  there  is  a  line  of  accumulated  material 
which  is  not  removed  by  the  tongue,  and  which,  undergoing  de- 
composition, affords  nutriment  to  micro-organisms  that  may  pro- 
duce substances  of  an  irritant  nature.  Besides  this,  there  also 
exist  in  this  locality  numerous  glands  which  secrete  mucin  and 
whose  function  may  be  changed  by  the  influence  of  the  above- 
named  irritating  substances,  so  that  the  secretion  itself  may  become 
irritating  and  injurious  in  its  effect,  and  it  is  further  stated  that  the 
degree  of  irritation  influences  proportionately  the  character  of  the 
calculus  thus  formed. 

The  formation  of  calculi  in  general  and  the  varieties  of  dental 
calculi  are  well  desciibed  in  the  following  quotations  from  Prof. 
Burchard's  paper  in  the  Dental  Cosmos  for  January  1898: 

Calculary  deposits  found  in  any  part  of  the  body  are  formed  in  conse- 
quence of  a  precipitation  of  calcium  salts  in  some  organic  menstruum; 
the  calculus  consists  of  a  combination  of  the  calcium  salts  with  the  organic 
material.  There  must  first  be  established  conditions  under  which  calcium 
salts  previously  held  in  solution  are  precipitated.  These  conditions  vary 
in  different  situations  in  the  body,  as  also  does  the  chemical  composition 
of  the  precipitated  salts  and  of  the  menstruum  in  which  they  are  deposited 
and  cemented  together.  The  most  common  of  the  cementing  materials  is 
mucin  and  allied  substances.  In  calculi  found  in  some  situations  in  the 
body,  notably  in  the  bladder  and  gall-duct,  the  albuminous  stroma  in  which 
calcic  material  is  contained  is  of  distinctive  structure,  the  form  of  the  cal- 
culus  remaining  after  the  calcium   salts   have  been  removed  through  the 

action  of  dilute  acids There  are  certainly  five  distinct  varieties, 

— distinct  in  that  each-  is  associated  with  distinctive  pathological  states,  and 
chemical  conditions. 

Three  of  these  classes — two  of  them  undoubtedly — are  of  salivary 
origin,  the  doubtful  member  of  at  least  partial  salivary  origin,  while  two 
of  them  may  be  fitly  termed  serumal,  or  hematogenic. 

The  first  class  consists  of  the  yellowish-white  deposits  found  upon  the 
buccal  surfaces  of  upper  molars.  The  second  class  includes  the  calculi 
found  first  upon  the  lower  anterior  teeth,  opposite  the  ducts  of  the  sub- 
maxillary and  sublingual  glands.  The  third  class  comprises  those  dark, 
flattened,  hard,  scale-like  calculi  found  immediately  beneath  the  gum 
margin.  This  variety  is  at  times  associated  with  the  first  and  second 
classes.  The  fourth  class  consists  of  those  small  nodular  calculi  found 
deep  in  the  pockets  of  pyorrhea  cases  and  upon  the  apices  of  roots  in  cases 
of  long-continued  apical  abscess.  The  fifth  class  includes  those  deposits 
which  are  found  upon  the  sides  of  roots  in  cases  of  gouty  necrosis  of  the 
pericementum,  and  which  exhibit  in  some  degree  a  reaction  to  the  murexid 
test, — i.e.  which  contain  urates.     .     .     . 

The  first  class  of  calculi — those  found  upon  the  buccal  faces  of  upper 
posterior  teeth — present  these  features:     They  are  yellowish-white,  and  are 


PYORRHEA    AL\'E(JLARIS.  II3 

comparatively  soft  and  friable.  They  dissolve  readily  in  dilute  hydro- 
chloric acid  with  the  evolution  of  carbon  dioxid,  and  leave  but  little  detritus 
and  apparently  no  distinct  evidences  of  an  organic  stroma, — i.e.  they  are 
largely  composed  of  calcium  carbonate,  with  a  minimum  admixture  of 
organic  material.  The  parotid  secretion  to  which  they  owe  their  origin 
contains  a  much  greater  percentage  of  calcium  carbonate  than  of  the 
phosphate,  and  instead  of  mucin  contains  a  globulin 

The  calculi  of  the  second  class — those  formed  first  upon  the  lingual 
faces  of  the  lower  anterior  teeth — are  made  up,  in  large  part,  of  calcium 
phosphate  combined  with  mucin.  Like  the  previously  described  form  they 
may  contain  dead  epithelial  cells,  leptothrix,  and  foreign  materials.  A  for- 
eign substance  which  has  found  lodgment  frequently  acts  as  the  nidus  of  a 
deposit.  A  rough  or  irregular  surface  will  also  determine  a  point  of 
deposit 

The  next  variety  of  calculus — the  small,  dark,  scaly  deposits  found 
beneath  the  gum  margin  which  excite  the  most  common  and  most  curable 
variety  of  pyorrhea  alveolaris, — is  intimately  associated  in  its  formation  with 
a  pre-existing  marginal  gingivitis.  After  having  formed,  these  calculi  act 
as  persistent  irritants  to  continue  the  gingivitis  and  excite  degenerative 
changes  in  the  pericementum.  This  is  the  variety  of  calculus  usually 
described  as  serumal.  Furthermore,  all  deposits  upon  tooth-roots  other 
than  those  described  have  been  included  under  this  head, — an  error  of 
classification,  as  will  be  seen 

When,  however,  gingivitis  has  been  excited  by  the  presence  of  calculi 
of  the  first  and  second  classes,  the  hard,  sparse  calculus  frequently  forms 
beneath  and  about  the  edges  of  the  first  calculus  at  its  point  of  contact 
with  the  gum. 

The  presence  of  these  deposits  excites  progressive  degenerative  changes 
and  destruction  of  the  retentive  apparatus  of  the  tooth,  the  pericementum 
and  alveolar  process,  in  a  distinctive  manner.  There  is  a  recession  of 
pericementum,  which  keeps  pace  with  the  atrophy  of  the  alveolar  wall. 
The  walls  of  the  pocket  between  the  soft  tissues  and  the  tooth  become 
infected  early  by  pyogenic  organisms,  and  pus-formation  occurs,  hastening 
the  pericemental  destruction.  If  the  tooth  be  extracted  at  a  comparatively 
early  date,  a  dark,  scaly  calculus  is  seen  to  occupy  the  cervical  portion  of 
the  root;  beyond  this  is  an  area  of  tooth-denudation  in  which  no  deposits 
are  found,  and  toward  the  apex  the  shreds  of  the  thickened  pericementum. 
There  is  always  a  space  between  the  pericementum  and  calculus,  showing 
that  detachment  or  loss  of  the  pericementum  is  in  advance  of  the  calculus. 
If  the  tooth  be  extracted  or  examined  after  pyorrhea  (pus-flow)  has  per- 
sisted for  a  long  time,  it  is  common  to  find  the  areas  of  denudation  lying 
beyond  the  primary  calculus  to  be  incrusted  by  numbers  of  small,  hard, 
dark,  nodular  deposits,  which  lie  in  the  area  of  necrosis  as  small  islands. 
This  is  the  fourth  variety  of  calculus, — called  a  variety  because  its  appear- 
ance has  such  an  association  with  long-continued  suppuration  that  it  seems 
a  consequence  of  such  conditions 

The  next,  or  fifth,  class  of  calculus  is  that  regarding  which  there  has 
been  so  much  controversy  during  the  past  five  years, — gouty  calculi.     These 

9 


114  THE    PRACTICE    OF    DENTAL    MEDICINE. 

deposits  may  be  associated  with  the  subgingival  calculi  and  those  of 
pyogenic  origin,  so  that  much  confusion  has  arisen  from  the  lack  of  dis- 
crimination. 

A  typical  gouty  incrustation  presents  these  features:  A  tooth  exhibits 
the  symptoms  of  acute  apical  pericementitis;  a  bistoury  passed  into  the 
apex  of  the  swelling  over  the  root  may  give  vent  to  a  glairy,  mucus-like 
discharge,  or,  in  some  cases,  pus  flows.  A  further  examination  may  reveal 
the  loss  of  underlying  alveolar  wall;  exposing  the  root,  which  is  partially 
denuded  of  pericementum  in  this  area  of  denudation,  the  presence  of  a 
calculus  is  detected.  The  pulp  responds  to  tests  for  its  vitality,  and  the 
gum  margin  and  marginal  pericemental  attachment  appear  to  be  intact. 
A  chemical  test  of  the  calculus  shows  it  to  respond  in  some  degree  to  the 
murexid  test, — i.e.  it  contains  urates.  These  deposits  in  their  typical  form 
are  irregular  and  more  friable  than  either  the  subgingival  deposits  or  the 
other  root-deposits  named.  The  bulk  of  the  calculus  is  made  up  of  calcium 
phosphate,  a  common  associate  of  deposits  of  urates  in  other  parts  of  the 
body. 

It  has  been  stated  that  pyorrhea  is  a  catarrhal  process:  but 
what  is  catarrh?  It  may  be  applied  to  various  conditions  of 
mucous  membrane  throughout  the  body,  but  in  America  the  term 
is  usually  understood  to  indicate  an  inflammation  of  the  mucous 
membrane  of  the  air-passages.  If,  as  has  been  stated,  pyorrhea 
alveolaris  has  its  origin  in  the  oral  cavity  and  is  a  catarrhal  pro- 
cess, being  due,  as  is  claimed,  to  the  same  influences  that  produce 
catarrh  in  other  regions,  then  we  should  be  likely  to  see  the 
catarrhal  process  in  surrounding  parts.  But  this  is  not  the  case; 
many  cases  of  catarrh  exist  with  no  sign  of  what  is  called 
pyorrhea  alveolaris.  It  is  argued  that  particles  of  dust,  shock  from 
colds,  and  changes  of  temperature  from  breathing  through  the 
mouth,  cause  a  catarrh  of  the  oral  cavity  in  much  the  same  way  as 
it  is  produced  in  the  nose;  but  as  a  matter  of  fact  we  do  not  hold 
that  nasal  catarrh  or  rhinitis  is  produced  in  this  way;  and  besides, 
the  function  and  structure  of  the  nasal  mucous  membrane  and  the 
turbinated  bodies  are  altogether  different  from  those  of  the  gum 
tissue  and  mucous  membrane  of  the  mouth. 

Pyorrhea  alveolaris  and  nasal  catarrh  are  found  in  a  large  pro- 
portion of  patients,  and  it  is  therefore  not  an  uncommon  occur- 
rence to  find  these  two  diseases  associated  in  the  same  person,  as 
other  distinct  diseases  often  occur  together;  for  example,  hay 
asthma  and  ordinary  rhinitis,  or  stomatitis  catarrhalis  and  stoma- 
titis herpetica. 

If  the  disease  is  catarrhal,  why  does  it  attack  the  pericementum 
and  contisfuous  tissues  to  the  exclusion  of  the  entire  mucous  mem- 


PYORRHEA    ALVEOLARIS.  II5 

brane  of  the  mouth?  This  is  a  disease  of  adult  Hfe,  but  it  is  not 
infrequently  observed  in  young  people  under  fifteen  years  of  age. 
It  cannot  be  said  to  exist  more  commonly  in  those  whose  diet  is 
luxurious  than  in  those  who  live  on  plain  food.  In  legard  to  the 
condition  of  health,  many  pass  the  dentist's  observation  as  physi- 
cally sound  who  are  really  not  so;  for  many  a  strumous  diathesis 
lurks  beneath  a  fair  skin  and  ruddy  appearance.  When  the  physi- 
cal examination  becomes  more  searching,  thorough,  and  exact,  the 
systemic  conditions  will  be  revealed  and  the  cause  found. 

The  successful  treatment  of  diseases  depends  largely  upon  the 
detection  and  elimination  of  the  first  cause;  for  there  are  first, 
second,  and  third  causes,  much  after  the  manner  of  a  row  of  bricks 
in  which  one  falls  upon  the  other  until  those  at  a  considerable  dis- 
tance feel  the  effects  of  the  fall  of  the  first.  This  is  why  a  perma- 
nent cure  of  pyorrhea  is  not  effected  when  the  calculus,  or  the 
direct  cause,  has  been  removed,  for,  if  previous  causes  continue  to 
act,  the  deposit  will  be  formed  again. 

Statements  have  been  made  to  the  effect  that  if  the  tartar 
deposit  could  be  eliminated  from  the  list  of  causes  of  pyorrhea  the 
■disease  itself  would  practically  disappear,  to  which  answer  may  be 
made  that  the  way  to  eliminate  the  tartar  as  a  cause  is  by  removing 
the  constitutional  condition  which  produces  it;  and  the  difficulty 
of  doing  this  explains  the  inability  which  all  practitioners  have  in 
curing  disease. 

It  has  been  said  by  Dr.  M.  L.  Rhein,  of  New  York,  that  "Every 
known  disease  that  afflicts  the  human  organism  often  manifests 
itself  as  pyorrhea  alveolaris,  and  in  many  it  is  the  first  marked 
symptom." 

Pyorrhea  has  not  been  noted  as  being  an  accompaniment  of 
tetanus,  diphtheria,  or  psoriasis,  and  the  same  may  be  said  of  it  in 
its  relation  to  most  other  diseases.  No  one  will  deny  the  possi- 
bility of  pyorrhea  occurring  incidentally  during  any  of  these  dis- 
eases; but  this  is  quite  a  different  thing  from  noting  it  as  being 
inseparably  connected  with  one  or  all  of  them.  In  order  to  con- 
nect pyorrhea  with  any  of  these  diseases  it  should  occur  during  the 
disease  and  disappear  with  it  also. 

Dr.  Cravens  believes  that  the  cause  of  so-called  serumal  cal- 
culus is  in  the  pus  itself,  and  that  it  should  be  called  pyonal  cal- 
culus. Dr.  Geo,  B.  Clement,  of  Macon,  Miss.,  holds  that  the 
lesion  within  the  socket  is  a  disease  or  the  result  of  a  disease  of  the 


Il6  THE    PRACTICE    OF    DENTAL    MEDICINE. 

cementum;  that  there  is  an  obstruction  of  the  canalicuH  and  lacunas 
which  is  the  result  of  a  deposit  of  lime  salts,  thus  solidifying  the 
cementum  and  cutting  off  the  vital  connection  between  it  and  the 
pericementum. 

The  late  Dr.  Thomas  Evans,  of  Paris,  reported  that  he  had 
observed  many  cases  of  pyorrhea  connected  with  affections  of  the 
kidneys,  and  predicted  that  pyorrhea  will  come  to  be  recognized 
as  a  manifestation  of  kidney  trouble.  Others  regard  pyorrhea 
as  one  of  the  symptoms  of  gout. 

Prof.  C.  N.  Peirce  has  described  two  different  pathological 
states  included  in  the  term  pyorrhea  alveolaris.  He  believes  that 
the  pericementitis  is  in  each  case  associated  with  a  calcic  deposit; 
but  that  the  origin  of  one  is  in  the  saliva,  and  that  of  the  other  is 
in  the  blood.  Prof.  Peirce  presents  two  terms,  original  with  him- 
self, to  designate  these  conditions.  The  form  of  so-called  pyor- 
rhea having  its  origin  in  the  saliva  is  termed  ptyalogenic  calcic 
pericementitis,  with  the  intention  of  conveying  the  idea  that  its 
origin  is  local,  peripheral,  and  salivary.  The  form  having  its 
origin  in  the  blood  is  termed  hematogenic  calcic  pericementitis, 
expressing  the  idea  that  in  its  origin  it  is  constitutional,  central, 
and  associated  with  some  modification  of  the  normal  composition 
of  the  blood-plasma.  Dr.  Peirce  found  that  upon  the  removal 
of  the  deposit  from  teeth  which  were  lost  in  consequence  of  this 
form  of  pyorrhea,  the  chemical  analysis  showed  in  every  case  that 
the  deposit  was  a  combination  of  calcic  urate  and  sodic  urate  with 
some  calcic  phosphate  and  carbonate.  The  existence  of  the 
urates,  in  which  uric  acid  is  the  predominating  element,  shows  that 
the  deposit  is  a  precipitate  from  blood-exudation,  that  the  irrita- 
tion is  of  constitutional  origin,  and  that  the  disease  pyorrhea 
alveolaris  is  but  another  phase  of  the  uric  acid  or  gouty  diathesis. 
The  explanation  of  the  presence  of  uric  acid  has  not  been  given, 
but  the  fact  has  been  established  of  its  presence  in  the  blood,  of  its 
non-diffusibility  and  consequent  retention,  and  the  formation  of 
the  urates  found  in  many  portions  of  the  body.  In  view  of  these 
facts  Dr.  Peirce  states: 

Inasmuch  as  all  portions  of  the  body  have  been  shown  by  pathologists 
to  be  liable  to  uric  acid  deposits,  it  is  not  at  all  strange  that  the  alveolo- 
cemental  membrane,  composed  largely  of  connective  tissue,  should  also 
become  a  depot  for  uric  acid  deposits.  It  is  more  than  probable  that  as  a 
predisposing  cause  there  might  coexist  some  impairment  in  the  nutrition 
of  this  membrane  dependent  upon  either  local  mechanical  force  or  some 


PYORRHEA    ALVEOLARIS.  II/ 

obscure  faulty  innervation.  However  this  may  be,  the  mere  presence  of 
these  sahs  leads  to  the  conclusion  that  here  as  elsewhere  they  are  derived 
from  the  blood  by  or  through  the  medium  of  the  lymph-stream.  With  the 
absorption  of  the  excess  of  lymph,  the  residual  salts  become  precipitated 
upon  the  cemental  surface.  It  is  for  this  reason  that  I  regard  the  deposition 
of  uric  acid  as  of  blood  origin,  and  the  disease  pyorrhea  alveolaris  as  one 
of  the  local  manifestations  of  the  constitutional  state  familiar  to  all  patholo- 
gists as  the  uric  acid  or  gouty  diathesis.  Assuming  now  that  the  deposition 
of  uric  acid  salts  is  the  primary  cause  of  this  form  of  pericementitis,  what 
would  naturally  be  the  successive  stages  in  its  evolution?  As  the  current 
of  the  lymph-stream  is  directed  for  the  most  part  toward  the  cementum, 
through  its  borders  or  periphery  into  the  lacunse  and  canaliculi,  and  finally 
in  the  reverse  direction,  it  is  not  difficult  to  see  why  the  deposit  should 
take  place  on  the  surface  of  the  cementum  as  well  as  in  the  meshes  of  the 
alveolo-cemental  membrane.  The  constant  deposition  and  pressure  of  these 
insoluble  salts  will  act  as  irritants,  engendering  the  well-known  inflamma- 
tory states,  viz.  congestion,  exudation,  impaired  nutrition,  tissue-disorgani- 
zation, and  formation  of  pus.  These  changes  take  place  here  as  elsewhere 
in  the  immediate  vicinity  of  the  irritation — that  is,  on  the  cemental  aspect 
of  the  membrane — leading  to  its  detachment  from  the  cementum  and  the 
development  of  a  pus-pocket. 

It  is  the  writer's  belief  that  the  disease  known  as  pyorrhea 
alveolaris  is  in  nearly  every  case  the  result  of  a  constitutional 
diathesis;  that  the  teeth  are  in  these  cases  the  victims  of  the  local 
manifestation;  that  the  diathesis,  in  whatever  form  it  may  be,  mani- 
fests itself  in  other  organs  besides  the  teeth;  and  that  to  demon- 
strate the  connection  of  a  diathesis  with  the  teeth  it  must  be  shown, 
not  that  its  symptoms  always  coexist  with  pyorrheal  symptoms,  but 
that  the  condition  of  the  pyorrhea  varies  in  intensity  with  the  con- 
dition of  the  diathesis;  or,  to  put  it  another  way,  that  curing  the 
diathesis  cures  the  pyorrhea.  If  removing  the  teeth,  followed  by  a 
cure  of  the  local  pyorrhea,  proves  the  disease  to  be  local,  it  is  still 
necessary  to  point  out  the  local  cause;  for  the  teeth  themselves 
cannot  be  held  to  be  a  cause,  since  in  that  case  every  one  so  un- 
fortunate as  to  have  teeth  would  pay  the  penalty  with  pyorrhea. 
Moreover,  constitutional  symptoms  may  yet  be  found  to  be  pres- 
ent. If  it  is  held  that  poison,  at  first  local,  has  infected  the  whole 
system,  still  we  ask  for  the  origin  of  the  local  manifestation,  and 
may  even  expect  that,  when  the  teeth  have  been  removed,  tartar 
will  not  collect  on  artificial  plates  and  the  constitutional  symptoms 
will  disappear  or  at  least  improve  in  a  reasonable  degree,  provided 
structural  change  and  otherwise  permanent  injuries  have  not 
taken  place. 


Il8  THE    PRACTICE    OF    DENTAL    MEDICINE. 

It  is  of  course  acknowledged  that  the  immediate  or  direct  cause 
may  be  readily  seen  in  the  irritating  foreign  body  known  as  tartar, 
or  the  deposit  of  whatever  character;  but  in  order  to  cope  success- 
fully with  the  disease,  we  must  look  for  a  cause  back  of  this,  and  if 
possible  find  the  first  cause.  It  is  possible  not  only  that  constitu- 
tional derangements  and  diatheses  may  be  unperceived  by  the  ordi- 
nary observer,  but  also  that  persons  in  whom  they  exist  may  be 
unaware  of  any  abnormal  or  unhealthy  condition;  for  instance,  a 
patient  of  twenty-four  years  has  an  offensive  ozena,  and  certainly 
has  a  constitutional  diathesis  underlying  this  condition;  but  this 
patient  presents  a  healthy  appearance,  and  there  are  no  other 
symptoms  of  physical  disturbance.  It  is  to  be  supposed,  there- 
fore, that  many  conditions  of  the  teeth  and  gums  in  persons  other- 
wise in  good  health  are  due  to  an  obscure  constitutional  taint,  such 
as  that  of  scrofula  or  rheumatism.  The  writer  had  a  patient,  a 
physician,  the  subject  of  diabetes,  whose  teeth  had  loosened  to  an 
alarming  extent  with  so-called  pyorrhea;  after  an  exclusive  anti- 
diabetic diet  they  began  to  tighten  and  the  deposit  ceased  to  accu- 
mulate, and  this  condition  has  been  maintained  for  nearly  two 
years. 

Pathology. — On  inspection,  the  ordinary  and  so-called  pyor- 
rheal  cases  present  a  pocket  or  space  between  the  tooth  and  gums 
from  which  there  is  a  flow  of  pus,  which  may  be  profuse  or  very 
slight.  The  gum  shows  varying  shades  of  red  to  purple.  To 
quote  Prof.  Miller,  of  Berlin:  "Pyorrhea  alveolaris  is  a  chronic 
suppurative  inflammation  of  the  peiiosteum  with  more  or  less 
severe  inflammation  of  the  gums  and  necrosis  of  the  alveolar  pro- 
cess of  the  diseased  teeth." 

Dr.  W.  C.  Barrett  thus  describes  further  the  pathology  of  this 
disease: 

The  pocket  once  formed  and  infected  with  septic  organisms,  an  irrita- 
tion and  inflammation  of  the  vascular  tissues  succeeds,  perhaps  due  to  the 
more  direct  action  of  the  fungi,  or  possibly  consequent  upon  the  changes 
in  the  tissues  beneath;  with  an  osteitis  and  caries  of  the  bone  due  to  the 
secondary  products  of  the  growth  of  the  organisms,  and  a  suppurative 
condition  of  the  pericementum  dependent  upon  a  pyogenic  organism.  All 
of  these  pathological  changes  are  possible  because  of  some  predisposing 
diathesis,  or  a  condition  of  atony. 

It  is  well  understood  that  accretions  may  form  in  any  part  of 
the  body  as  a  deposit  from  purulent  matter  in  an  inflamed  area, 
and,  although  tTiere  are  some  differences  of  opinion,  the  following 
seems  to  be  a  rational  explanation:  Calcareous  matter  is  normally 


PYORRHE.V    ALVEOLARIS.  II9 

contained  in  the  blood,  being  held  in  solution  by  carbon  dioxid. 
When  the  circulation  is  impeded  from  any  cause  the  diffusible 
carbon  dioxid  is  absorbed  by  the  tissues,  or  combines  to  form  new 
compounds,  thus  leaving  the  calcareous  matter  t6  be  deposited. 
In  regard  to  the  destruction  of  the  alveolar  process  and  the  peri- 
cementum, while  it  is  not  denied  that  it  is  a  necrosis,  in  some  forms 
of  this  disease  it  appears  as  a  process  of  absorption,  governed  by 
the  laws  which  usually  determine  bone-softening.  Prof.  C.  N. 
Peirce  thus  speaks  regarding  this  subject: 

If  the  periosteum  of  any  bone  becomes  the  seat  of  inflammation,  an 
exudation  is  poured  out  from  its  inner  surface,  which  is  in  close  contact 
with  the  compact  tissue.  The  exudation  exerts  pressure  on  the  bone, 
interferes  with  its  nutrition,  and  in  consequence  leads  to  softening  arid 
absorption.  If  the  tension  be  not  relieved  by  the  removal  of  the  exudation, 
the  softening  increases  and  necrosis  results;  but  if  the  pressure  be  removed 
in  sulticient  time,  the  progressive  pathological  state  never  passes  beyond 
the  stage  of  softening  and  absorption.  In  pericementitis  the  effusion 
exerts  a  pressure  in  both  directions,  toward  the  cementum  and  toward  the 
alveolar  process.  The  constant  pressure  of  the  exudation  would,  by  inter- 
ference with  the  nutrition  of  the  process,  lead  not  only  to  softening  and 
absorption,  but  to  necrosis  also,  if  it  were  not  that,  as  the  pus  accumulates 
and  the  pressure  rises,  the  fluid  takes  the  line  of  least  resistance  and  bur- 
rows toward  the  gum  margins,  and  so  relieves  the  pressure  on  the  alveolar 
process  before  complete  strangulation  of  the  tissues  takes  place;  but,  as 
the  pressure  from  pus-accumulation  rises  and  falls  from  time  to  time,  there 
will  be  periodical  compressions  with  some  pain,  and  gradual  absorption. 
If  necrosis  of  the  process  should,  however,  occur  in  any  appreciable  amount, 
we  should  have  it  demonstrated  by  exfoliation  and  sequestration. 

Symptoms. — The  apparent  condition,  or  symptom,  that  appears 
in  the  cases  of  large  deposits  of  salivary  calculus  is  at  first  a  slight 
reddening  of  the  gum  at  its  margin,  caused  by  a  deposit  so  slight 
that  an  instrument  may  be  needed  to  detect  it;  but  if  it  should  be 
allowed  to  collect,  its  size  might  increase  to  a  degree  only  limited 
by  the  space.  As  a  rule  the  concretions  are  broken  ofif  by  the 
patient,  often  after  attaining  a  size  much  larger  than  the  tooth 
itself.  As  the  deposit  increases,  the  inflammation  of  the  gum  aug- 
ments and  destruction  of  all  the  approximating  tissues  goes  on  as 
the  deposit  advances  upon  them,  thereby  loosening  the  teeth;  but 
they  are  not  as  a  rule  painful  or  tender  to  the  touch.  This  process 
may  go  on,  accompanied  by  fetid  breath  and  a  disagreeable  taste 
in  the  mouth,  and  followed  by  indigestion  with  all  its  symptoms 
and  consequences,  until  the  teeth  are  lost. 

In  the  serumal  form  the  advance  of  the  disease  is  more  stealth- 


120  THE    PRACTICE    OF    DENTAL   MEDICINE. 

ily  accomplished,  there  is  less  inflammation  of  the  gums,  less 
absorption,  and  consequently  less  loosening  of  the  teeth;  often  the 
only  diagnostic  sign  being  the  ability  to  pass  an  instrument  under 
the  gum  beyond  the  health  limit.  When  this  deposit  is  unaccom- 
panied by  the  salivary  form,  it  may  take  years  to  produce  serious 
or  noticeable  symptoms. 

Duration. — The  disease  is  unlimited  in  duration,  with  a  ten- 
dency to  increase  with  age.  It  may,  however,  subside  or  disappear 
with  some  physiological  change  in  the  patient's  general  condition. 

Prognosis. — Unfavorable  as  to  cure. 

Diagnosis. — Attention  to  the  pathology  and  symptoms  will 
afford  ample  means  for  diagnosis.  The  salivary  form  is  unmis- 
takable. The  only  difficulty,  if  any,  will  be  in  making  a  dififerentia- 
tion  between  the  serumal  form  and  phagedenic  pericementitis;  or 
possibly  the  latter  may  be  simulated  by  an  alveolar  abscess  which 
discharges  at  the  margin  of  the  gum,  in  which  case,  however,  the 
condition  would  be  confined  to  the  teeth  thus  affected. 

Treatment. — The  treatment  has  hitherto  consisted  almost 
wholly  in  local  measures,  and  principally  in  the  removal  of  the 
foreign  body.  In  all  the  forms  it  is  absolutely  necessary  to  remove 
all  irritating  substances.  If  there  is  a  physical  disability  in  any 
part  of  the  system,  whether  we  are  clear  as  to  its  direct  causation 
of  the  pyorrhea  or  not,  it  would  be  well  to  treat  this  condition  with 
a  view  to  helping  the  body  to  resist  the  local  influence.  In  the 
absence  of  definite  constitutional  causes  it  is  evident  that  there 
can  be  no  specific  systemic  treatment.  There  are  many  cases 
having  large  salivary  deposits,  and  other  forms  of  deposit,  in  which 
there  is  no  apparent  deviation  from  perfect  health,  but  in  which 
there  exists  nevertheless  a  diathesis,  or  some  inherited  constitu- 
tional taint,  that  finds  local  expression  in  many  ways;  in  such 
cases  we  cannot  advise  experimenting  with  drugs,  but  can  only 
remove  the  deposits  and  treat  the  resulting  pocket  and  inflamma- 
tion. The  recent  methods  of  doing  this  are  as  follows:  By  means 
of  the  various  scalers  the  deposits  are  removed  as  thoroughly  as 
possible  (and  this  will  apply  to  all  the  varieties),  after  which  some 
acid  solvent  is  applied  to  dissolve  any  remaining  particles. 

There  are  two  acid  solvents  which  have  been  commended,  viz. 
a  twenty-five  per  cent,  solution  of  sulfuric  acid,  and  a  saturated 
solution  of  trichloracetic  acid.  For  the  application  of  these  reme- 
dies orange-wood  sticks,  shaped  very  thin  like  a  chisel  scaler  and 


PYORRHE.\  ALVEOLARIS.  121 

seared  by  passing  through  the  flame  of  an  alcohol  lamp,  may  be 
dipped  in  the  acid,  and  passed  down  along  the  root  much  in  the 
same  way  as  a  scaler  would  be  used.  In  removing  the  deposits, 
by  whatever  method,  care  should  be  taken  not  to  lacerate  the  soft 
tissues.  The  remaining  deposits  being  thus  dissolved,  two  things 
are  to  be  done,  viz.:  ist.  To  remove  the  softened  and  de- 
tached particles  of  deposit;  2d.  To  neutralize  any  remaining  acid. 
The  first  may  be  accomplished  by  means  of  a  hypodermic  syringe 
with  a  needle  having  a  smooth,  rounded  point,  from  which  some 
antiseptic  solution  is  thrown  forcibly  under  the  gum.  Such  solu- 
tions may  contain  mercuric  bichlorid  i  to  2000,  or  three  per  cent, 
pyrozone. 

Another  method  of  removing  debris  from  the  pockets  is  that  in 
which  the  above  solutions  are  sprayed  into  the  pockets  by  an 
atomizer  connected  with  a  tank  of  compressed  air,  which  throws 
a  warm  spray  with  great  force.  And  still  another  method  consists 
in  the  use  of  a  very  fine  and  nearly  smooth  broach  wrapped  with 
cotton,  which  after  being  dipped  in  some  antiseptic  solution  is 
passed  around  the  root. 

The  second  essential  thing  to  be  accomplished  has  been  partly 
done  in  the  effort  to  wash  out  the  remaining  particles  of  the 
deposit;  but  to  make  it  certain  that  all  acid  is  neutralized,  a  paste 
of  sodium  bicarbonate  should  be  introduced  into  the  pocket.  Fol- 
lowing this.  Dr.  James  Truman  advises  the  introduction  into  the 
pocket  of  a  paste  of  quinin  sulfate  which  remains  until  the  next 
sitting,  in  two  or  three  days.  Dr.  Truman  advises  the  further  use 
of  quinin  at  subsequent  sittings,  and  prescribes  the  following 
mouth-wash  to  be  used  indefinitely: 

R — Hydronaphthol,  gr.  xx; 

Alcoholis, 

Aquse,  aa.  oj.         M. 

Sig. — Half  a  teaspoonful  of  the  above  to  a  small  tumbler  of  water,  to 
be  used  twice  a  day,  in  the  morning  and  before  retiring  at  night. 

In  the  subsequent  treatment  by  the  patient  much  care  should 
be  exercised  in  order  not  to  reopen  wounded  surfaces,  and  to  this 
end  a  syringe  should  be  employed  to  direct  a  small  stream  of  water 
against  the  parts  for  cleansing  purposes. 

As  a  safe  astringent  to  place  in  the  patient's  hands,  the  writer 
has  made  use  of  the  tincture  of  catechu,  applied  full  strength  with 
a  camel's-hair  brush.  Much  may  be  done  by  careful  instruction 
of  the  patient  in  the  use  of  the  tooth-brush. 


122  THE    PRACTICE    OF    DENTAL    MEDICINE, 

If  the  teeth  are  very  loose,  it  is  essential  that  some  appliance  be 
placed  so  that  they  may  be  held  firmly,  for  it  is  obvious  that  while 
the  teeth  are  moving  to  and  fro,  no  attachment  can  form,  and  no 
union  or  healing  take  place.  In  cases  having  the  deposit  near  the 
apex  of  the  root  it  has  been  recommended  that  such  teeth  be 
extracted,  the  root  cleansed,  the  canal  filled,  and  the  tooth 
replanted;  all  being  done  under  antiseptic  conditions.  It  would 
seem  that  the  success  of  this  operation  would  depend  largely  upon 
the  amount  of  tissue  destroyed;  if  there  is  much  loss  of  membrane, 
it  might  be  a  better  practice  to  replant  a  sound  tooth  obtained  from 
some  other  source. 

Nitrate  of  silver  has  considerable  prominence  as  a  remedial 
agent  in  pyorrhea,  and  good  results  have  been  obtained.  The 
remedy  is  certainly  efficacious  and  has  a  wide  range  of  application, 
but  it  stains  the  teeth.  The  powdered  crystals  may  be  taken  up 
on  a  thin,  moistened  orange-wood  stick,  or  fused  to  the  end  of  a 
platinum  point,  made  very  thin  for  this  purpose. 

During  all  methods  of  treatment,  the  fact  should  be  kept  stead- 
ily in  mind  that  asepsis  in  the  mouth  always  acts  favorably  on  the 
disease. 


CHAPTER    XXIII. 
PHAGEDENIC  PERICEMENTITIS.* 

Definition. — A  destructive  inflammation  of  the  peridental  mem- 
brane. 

Etiolog-y. — The  etiology  of  this  form  of  pyorrhea,  by  reason  of 
its  close  relation  to  the  other  forms,  is  likewise  obscure.  In  its 
beginning  it  may  not  be  distinguished  from  an  ordinary  gingivitis, 
and  during  its  course  may  be  accompanied  by  some  of  the  other 
forms,  thus  obscuring  the  diagnosis.  The  part  which  micro-or- 
ganisms play  in  the  causation  of  this  disease  has  not  yet  been 
determined.t  They  are  always  present,  and  germicidal  remedies 
have  a  beneficial  effect. 

*  This  term,  suggested  by  Dr.  G.  V.  Black,  indicates  a  condition  nearly 
always  classed  as  pyorrhea  alveolaris,  from  which  it  is,  however,  essentially 
different  in  several  particulars. 

t  See  editorial  in  the  Dental  Cosmos  for  November  1898. 


PHAGEDENIC    PERICEMENTITIS. 


123 


Patholog-y. — The  prominent  characteristics  of  phagedenic  peri- 
cementitis are  the  destruction  of  the  peridental  membrane  and 
absorption  of  the  alveolar  process.  This  may  take  place  without 
calculus  of  any  kind.  The  membrane  is  destroyed  as  it  is  sepa- 
rated from  the  root  of  the  tooth.  The  gums  may  be  inflamed,  but 
not  necessarily  so.  (Fig.  9.)  As  the  destruction  of  the  mem- 
brane goes  on,  a  very  slight  space  or  pocket  may  be  formed,  which 

Fig.  9. 


Phagedenic  pericementitis.  (The  illustration,  taken  from  life,  shows  what  the  author 
believes  to  be  the  results  of  this  disease,  following  its  earlier  and  acute  stages.  The  teeth  are 
now  quite  firm,  considering  the  small  area  of  attachment;  there  is  no  inflammation,  and  the 
disease  does  not  appear  to  be  progressing  at  the  present  time.) 

contains  pus.     This  may  occur  upon  any  part  of  the  root,  or  at 
several  points  at  the  same  time. 

As  an  example  of  an  acute  form  of  the  disease,  Dr.  Black  cites 
several  cases,  one  of  which  is  given  here:  A  lady  who  had  con- 
sulted her  dentist  only  a  month  before  calling  on  Dr.  Black,  was 
informed  that  no  disease  could  be  found.  When  she  came  to 
Dr.  Black  she  showed  him  a  tooth  which  she  had  removed  two 


124  THE    PRACTICE    OF    DENTAL    MEDICINE. 

days  before  with  her  thumb  and  finger.  An  examination  revealed 
the  disease  in  progress  about  the  roots  of  several  remaining  teeth. 
In  this  case  there  were  no  deposits,  and  the  other  usual  evidences 
of  inflammation  and  disease  were  so  slight  as  to  be  unnoticed  by 
the  dentist.  Many  cases,  however,  have  been  accompanied  with 
pain  and  inflammation  of  the  surrounding  soft  tissues.     (See  Plate 

ni.) 

It  seems,  therefore,  that  in  this  form  of  pyorrhea,  while  the 
cases  are  usually  accompanied  by  deposits,  these  are  not  necessary 
to  the  destruction  of  the  membrane,  which  apparently  goes  on  just 
as  rapidly  when  there  are  no  deposits.  Besides  this,  in  cases 
having  deposits  an  examination  of  the  root  and  membrane  will 
show  that  the  destruction  of  the  membrane  has  proceeded  beyond 
the  limit  of  the  calculus. 

Symptoms. — The  expressions  of  this  condition  vary  with  the 
length  of  time  it  has  been  in  progress.  When  it  is  uncomplicated 
we  may  say  there  are  no  deposits.  After  a  time  pockets  are  formed 
which  are  deep,  but  not  broad,  as  in  those  cases  accompanied  by  a 
calcareous  deposit. 

There  is  often  looseness  of  the  teeth,  and  in  acute  cases  pain. 
The  gum  is  not  usually  inflamed,  but  has  receded  in  proportion  to 
the  time  the  disease  has  been  in  progress.  The  exposed  dentin  is 
sensitive,  and  the  teeth  are  often  sore  on  shutting  them  together. 
The  writer  has  seen  oral  conditions  which  he  believes  to  be  symp- 
tomatic of  this  disease,  in  which  there  was  swelling  and  redness  of 
the  gum,  tenderness  on  percussion  of  the  adjacent  teeth,  but  no 
discharge  of  pus  or  abnormal  separation  of  the  gum  at  its  margin; 
but  these  symptoms  disappeared  after  a  few  weeks,  during  which 
time  constitutional  treatment  was  employed. 

Prognosis. — The  prognosis  is  generally  discouraging,  as  relat- 
ing to  cure.  The  treatment  is  palliative  and  prophylactic,  and 
sometimes  the  disease  may  thus  be  held  in  check  or  retarded  for 
an  indefinite  period. 

Diagnosis. — In  forming  the  diagnosis  a  suitable  exploring  in- 
strument is  passed  under  the  gum,  for  the  purpose  of  ascertaining 
the  amount  of  destruction  of  the  pericementum,  if  any;  and  to 
examine  for  absorption  of  the  alveolar  process.  The  destruction 
of  the  pericementum  and  absorption  of  the  alveolar  process  are  the 
main  features  by  which  it  is  distinguished  from  other  forms  of 
pyorrhea. 


PLATE    III. 


I'lIAGEDENlC    PKRICF.MKNTITIS. 


PHAGEDENIC    PERICEMENTITIS.  I25 

One  should  look  for  gouty  and  rheumatic  symptoms,  although 
they  are  not  always  markedly  pronounced,  and  in  some  cases  seem 
to  be  wanting  altogether. 

Treatment. — The  difficulty  in  treatment  consists  in  the  inacces- 
sibility of  the  parts  affected.  If  foreign  particles  or  calcareous 
deposits  have  formed  near  the  apex  of  the  root,  in  my  opinion  they 
cannot  be  thoroughly  removed  without  turning  aside  a  portion  of 
the  soft  tissue,  in  the  form  of  a  flap,  which  will  expose  the  surface 
to  be  operated  upon;  or  extracting  the  tooth,  which,  after  being- 
treated,  is  replaced.  It  is  important  after  every  surgical  procedure 
of  this  nature  that  all  blood-clots  be  washed  away,  as  they  may 
decompose  and  thus  hinder  the  process  of  repair.  Zinc  chlorid, 
twenty  grains  to  the  ounce  of  water,  is  an  excellent  astringent  to 
apply  to  the  pocket  or  parts  operated  upon,  and  a  ten  per  cent, 
solution  of  nitrate  of  silver  is  also  a  remedy  upon  which  great 
reliance  is  placed.  This  constricts  the  dilated  vessels  and  is  other- 
wise of  benefit. 

This  should  be.  followed  by  a  stimulating  treatment  such  as 
the  application  of  carbolic  acid  one  part  and  oil  of  cinnamon  two 
parts;  this  is  antiseptic  as  well  as  stimulant.  Campho-phenique 
may  be  used  in  the  same  way  with  good  effect. 

Sponge-grafting  is  not  to  be  commended,  on  account  of  the 
impossibility  of  maintaining  an  aseptic  condition  of  the  sponge 
after  it  has  been  placed  in  position. 

Replantation  has  not  shown  successful  results,  for  the  reason 
that  cases  in  which  it  has  been  practiced  have  been  so  far  advanced, 
and  as  its  reliability  has  not  been  fully  tested  the  practitioner  may 
well  be  reluctant  to  adopt  such  a  radical  measure  in  the  early 
stages  of  the  disease,  hoping  to  stay  its  progress  by  a  less  risky 
method. 

Systemic  treatment  in  these  cases  should  be  directed  toward  the 
prevention  and  removal  of  urates,  or  other  systemic  disturbances; 
but  cases  have  not  yet  been  tabulated,  nor  have  a  sufficient  number 
been  treated  in  order  to  form  a  definite  opinion  in  regard  to  it. 


126  THE    PRACTICE    OF    DENTAL    MEDICINE. 

CHAPTER    XXIV. 

DIFFICULT  DENTITION. 

Definition. — Difficult  or  abnormal  dentition  is  a  departure  from 
the  normal  and  purely  physiological  process,  attended  with  pain 
and  various  other  symptoms. 

Etiology. — That  normal  dentition  frequently  passes  the  border- 
Hne  which  marks  the  limit  of  a  physiological  process  into  a  patho- 
logical one  is  well  established.  The  eruption  of  the  deciduous  teeth 
occurs  at  a  time  of  life  when  the  organism  is  extremely  delicate  and 
susceptible,  and  at  a  time  which  is  well  known  to  be  the  period  of 
greatest  mortality.  The  organism,  being  thus  in  a  state  of  physio- 
logical activity,  is  more  easily  influenced  by  causes  which  tend  to 
produce  a  pathological  condition;  besides,  the  nervous  and  vas- 
cular excitability  of  teething  must  make  an  extra  drain  upon  the 
vital  forces  at  this  time,  thus  rendering  the  organism  less  able  to 
combat  any  injurious  influence  that  may  arise  in  any  part  of  it. 

This  being  true,  we  are  justified  in  assuming  that  diarrhea, 
convulsions,  irritating  and  painful  conditions  of  the  gums  and 
associate  parts,  may  be  due  to  teething  as  an  exciting  cause,  the 
action  of  which  was  made  possible  by  the  existence  of  a  predispo- 
sition either  inherited  or  brought  about  by  improper  food  or  cloth- 
ing, indigestion,  etc. 

Dr.  James  W.  White,  in  the  Dental  Cosmos  for  November, 
1890,  speaks  as  follows  regarding  the  sympathetic  and  physio- 
logical relations  of  the  mouth  to  other  parts  of  the  organism : 

Anatomically  considered,  no  other  portion  of  the  human  organism 
offers  such  a  complex  association  of  tissues  as  those  which  compose  the 
mouth;  no  other  has  such  diversified  physiological  functions,  and,  from  a 
pathological  standpoint,  no  such  significant  systemic  relations.  Its  various 
offices  (those  of  the  oral  cavity)  necessitate  a  no  less  varied  organization 
and  an  equally  varied  relation  with  other  structures.  The  wide  circle  of  its 
anatomical  and  physiological  sympathies  suggests  an  equal  circle  of  patho- 
logical complications,  and  indicates  the  diversity,  as  well  as  the  gravity,  of 
the  disturbances  dependent  upon  systemic  relations  to  which  its  lesions  may 
give  rise.  By  means  of  its  lining  mucous  membrane  the  mouth  is  related 
by  continuity  with  the  pharynx,  esophagus,  stomach,  and  intestinal  tract,  the 
larynx,  trachea,  and  bronchia,  and  by  contiguity  as  well  as  by  continuity 
with  the  eyes,  ears,  nares,  and  antra.     But  it  is  to  direct  or  sympathetic 


DIFFICULT    DENTITION.  12'] 

nervous  relations  that  the  most  formidable  disturbances  resulting  from  an 
interference  with  the  erupted  process  are  to  be  attributed.  The  terminal 
distribution  in  and  about  the  mouth  of  the  sensory  and  motor  branches  of 
the  trigeminus,  its  extensive  topographical  connections  and  their  relations 
to  the  heterogeneous  tissues  and  manifold  functions  concerned,  and  its 
association  with  the  great  sympathetic, — thus  connecting  the  teeth  with 
the  entire  organism, — explain  the  liability  to  aberrations  of  sensation, 
nutrition,  and  motion,  when  its  termini  are  the  seat  of  disordered  sensi- 
bility  

The  profound  disturbance  which  may  be  excited  in  an  infant  by  even  a 
slight  functional  disorder  is  a  matter  of  common  observation.  A  little 
irritation  of  the  larynx  will  produce  spasmodic  croup,  a  little  indigestible 
food  may  cause  convulsions,  and  almost  any  excitant  may  provoke  vomit- 
ing  The  balance  between  health  and  disease   in  an  infant  is 

delicately  adjusted,  and  a  slight  disturbance  will  incline  it  to  one  or  the 
other  side. 

Cholera  infantum  is  undoubtedly  aggravated  by  the  process 
of  tooth-eruption,  which  many  believe  may  be  considered  a  con- 
comitant cause;  but  we  take  into  consideration  also  that  at  this 
age  there  is  great  functional  activity  and  development  of  the  intes- 
tinal follicles,  and  thus  a  greater  liability  to  this  disease. 

Dr.  C.  N.  Peirce  says : 

Purely  normal  dentition  depends  upon  a  complete  correspondence 
between  the  development  of  tooth-germ  and  its  calcification  at  its  base,  or 
growing  extremity,  and  the  absorption  or  otherwise  removal  of  the  over- 
lying structures;  so  that,  as  the  soft  structures  are  solidified,  the  previously 
formed  and  dense  part  of  the  tooth  will  be  lifted  from  its  base,  and  thus 
prevent  impingement  upon  the  uncalcified  germ,  which  produces  consti- 
tutional disturbance.  When  this  is  indicated  the  lancet  should  be  thor- 
oughly used,  that  for  the  time  the  obstruction  to  the  advancing  crown  may 
be  entirely  removed. 

Pathology. — The  pathology  of  teething  involves  nice  points  of 
distinction,  for  while  this  process  is  purely  physiological,  it  is 
always  active  and  excessive,  and  approaches  so  nearly  the  border- 
line between  physiology  and  pathology  that  it  has  often  been  pro- 
nounced pathological  when  in  reality  it  was  only  a  physiological 
process  in  a  high  state  of  activity.  Again,  when  the  process  has 
quite  clearly  passed  into  a  distinct  pathological  condition,  there 
are  those  who  hold  that  tooth-eruption  is  still  a  normal  process, 
and  consequently  needs  no  local  treatment,  systemic  conditions 
being  treated  independently. 

There  are  certain  signs  which  should  distinguish  a  pathological 
condition  from  a  physiological  one,  and  if  the  general  condition  is 
such  that  it  produces  a  local  disturbance  in  the  mouth  connected 


128  THE    PRACTICE    OF    DENTAL    MEDICINE. 

with  teething,  it  ought  surely  to  be  recognized  and  treated  accord- 
ingly. 

On  inspection  of  the  mouth,  we  must  determine  whether  the 
redness  of  the  gums  is  normal,  taking  into  account  the  fact  that 
pressure  of  an  advancing  tooth  may  cause  a  blanching  of  the 
overlying  tissue.  This  condition,  however,  may  be  better  under- 
stood when  other  symptoms  and  conditions  are  noted.  We  may 
then  say  that  there  is  an  abnormal  redness  to  be  expected  in  cer- 
tain cases,  and  following  this,  tumefaction  and  ulceration. 

The  surrounding  parts,  such  as  the  tongue,  cheeks,  and  lips, 
may  be  similarly  affected  by  acid  secretions,  which  are  usually 
present. 

Pathological  conditions  of  other  and  remote  parts  of  the  body 
are  also  said  to  be  induced  by  the  process  of  dentition.  These  con- 
ditions are  indicated  b}'  various  S3'mptoms;  for  instance,  obstinate 
vomiting,  or  convulsions,  ceasing  only  when  the  teeth  have  per- 
forated the  gum. 

Symptoms. — In  looking  for  the  local  symptoms  of  difficult  den- 
tition we  should  make  allowance  for  certain  expressions  or  symp- 
toms which  accompany  the  eruption  of  the  teeth,  but  which  are 
physiological;  for  instance,  the  increased  flow  of  saliva,  which  is 
normal;  also  a  certain  amount  of  discomfort  which  this  occasions 
by  overflowing  the  mouth  and  irritating  the  skin;  and  the  general 
uneasiness  depending  upon  the  unusual  but  not  abnormal  amount 
of  tissue-change  necessary  to  the  process  of  tooth-eruption.  The 
discomfort  of  which  we  have  just  spoken  causes  the  child  to  seek 
relief  by  carrying  the  fingers,  or  any  hard  substance,  to  the  mouth 
and  biting, — a  symptom  recognized  in  every  household. 

This  normal  process  may  pass  into  a  pathological  condition, 
the  symptoms  becoming  more  pronounced;  the  gums  are  now 
painful  to  the  touch,  swollen,  and  often  of  a  glassy  or  glistening 
appearance.  The  color  may  vary  from  the  redness  of  the  earlier 
stages  to  a  darker  color,  although  the  erupting  tooth  may  cause 
anemia  of  the  gum  immediately  over  it.  The  extent  to  which  the 
general  system  is  affected  depends  upon  the  severity  of  the  local 
irritation.  Diarrhea  is  often  present,  but  even  this,  in  a  limited 
degree,  need  not  be  considered  pathological.  If  severe  and  pro- 
tracted, it  demands  attention  as  being  injurious  and  out  of  the 
range  of  physiological  action.  Through  reflex  irritation  various 
systemic  disturbances  may  occur,  as  eruptions  of  the  skin,  nervous 


DIFFICULT    DENTITION.  1 29 

derangement,  as  shown  by  fretfulness,  inability  to  sleep,  loss  of 
appetite,  etc. 

A  continuance  of  these  symptoms  may  lead  to  still  further  and 
more  serious  results.  Many  of  the  original  symptoms  continue, 
but  are  exaggerated;  the  little  patient  cries  out,  even  in  sleep,  and 
becomes  more  fretful  and  uneasy,  until  the  delicate  nervous  system 
can  stand  the  strain  no  longer.  There  is  then  a  lull  from  exhaus- 
tion, broken  by  convulsive  sobs;  the  temperature  and  thirst  in- 
crease; the  eyes  have  a  peculiar  brightness;  muscular  twitchings 
are  noticed,  and  the  child  closes  the  jaw  tightly,  or  grinds  the 
teeth;  these  latter  symptoms  give  warning  of  approaching  con- 
vulsions. 

Although  ordinary  tooth-eruption  should  rarely  be  held  respon- 
sible for  the  development  of  chorea,  there  is  no  doubt  that  any 
irritated  condition  of  the  teeth  and  surrounding  parts  may  bring 
about  an  attack.  Reports  of  cases  show  that  impacted  teeth,  per- 
sistent temporary  teeth,  and  non-erupted  teeth  have  caused  chorea, 
and  in  a  majority  of  such  cases  extraction  or  other  treatment  ha^s 
cut  short  the  attack. 

Infantile  paralysis  is  also  classed  among  the  diseases  incident 
to  dentition;  and  in  the  Lancet  for  February  28th,  i860,  Dr.  Brown- 
Sequard  speaks  of  a  case  of  paraplegia  in  which  the  paralysis  ap- 
peared at  the  very  beginning  of  the  second  dentition,  and  increased 
and  decreased  alternately  during  and  after  the  cutting  of  each  of 
the  three  molars.     Dr.  Fleiss,  in  the  Journal  for  Sick  Children,  says: 

When  a  child  during  the  first  or  second  dentition  is  suddenly  seized 
with  paralysis  in  one  arm,  or  of  the  whole  side  of  the  body,  or  is  affected 
in  only  a  part  of  the  same  without  any  obvious  external  cause,  this  is  to  be 
considered  as  a  paralysis  from  dentition,  and  an  accurate  examination  of  the 
mouth  will  confirm  this  diagnosis,  for  the  teeth  will  be  found  firmly  com- 
pressed with  the  gums. 

This  article  mentions  other  reflex  disturbances,  such  as  afifec- 
tions  of  the  eye  and  ear,  insanity,  etc.,  and  concludes  with  the  fol- 
lowing: 

Here,  then,  we  have  on  the  highest  authority  a  long  list  of  the  many 
ailments  that  may  be  consequent  upon  disordered  dentition.  Just  how  this 
occurs  in  some  instances  it  is  difificult  to  determine,  but  it  has  been  thor- 
oughly established  that  dental  irritation  may  induce  pathological  conditions 
in  other  organs  of  the  body,  or  in  the  nervous  structures  themselves,  even 
without  the  existence  of  any  subjective  intimations  of  pain  in  the  teeth; 
and  it  is  therefore  necessary  for  a  practitioner  to  distinguish  in  each  indi- 
vidual case  whether  the  disorder  is  consequent  upon   some  derangement 

10 


130  THE    PRACTICE    OF    DENTAL    MEDICINE. 

of  the  teething  process,  or  upon  an  abnormal  condition  of  some  other  organ 
or  organs,  of  which  the  dental  difHculty  itself  is  but  a  symptom. 

There  are  those  [says  Dr.  Berg]  who  believe  dentition  cannot  be  pro- 
ductive of  any  serious  pathological  disturbances,  but  they  are  of  right  in 
the  minority.  When  it  shall  have  been  proven  that  other  physiological 
processes,  like  puberty  and  the  cessation  of  the  menstrual  flow,  are  never 
productive  of  serious  morbid  states,  then  we  shall  give  credence  to  such  a 
view;  for  the  present  it  is  emphatically  the  opinion  of  the  vast  majority  of 
authorities  that  teething  is  frequently  the  only  assignable  cause  of  some 
of  the  diseases  occurring  during  the  dentitional  epoch. 

Diagnosis. — There  can  be  no  reasonable  difficulty  as  to  the 
diagnosis  of  teething,  for  the  age,  the  increased  flow  of  saliva,  the 
desire  to  bite  something,  the  appearance  and  condition  of  the 
gums,  should  be  sufficient  to  enable  one  to  form  a  conclusion  as 
to  the  character  of  the  disturbance.  The  more  serious  difficulty 
arises  when  we  are  called  upon  to  decide  whether  teething  is  an 
essential  factor  in  producing  other  diseases  or  expressions  of  dis- 
ease in  remote  parts  of  the  body.  In  the  consideration  of  this 
question,  two  things- should  be  borne  in  mind,  viz.  that  it  is  possible 
for  other  causes  to  co-operate  with  teething  to  produce  convul- 
sions and  constitutional  disturbances,  and  that  another  cause,  such 
as  an  overloaded  stomach,  may  be  sufficient  in  itself  to  produce 
these  expressions  entirely  aside  from  teething.  In  view  of  these 
facts  it  is  well  to  eliminate  other  possible  causes,  so  far  as  possible, 
before  deciding  that  teething  alone  is  responsible. 

Treatment. — For  the  immediate  relief  of  the  congestion  and 
possible  pressure  of  an  advancing  tooth,  lancing  the  gums  not 
only  assists  in  removing  this  condition,  but  relieves  blood-pressure 
in  the  surrounding  parts  as  well.  Caution  should  be  used  in  this 
as  in  other  surgical  procedures,  to  avoid  operating  when  a  hemor- 
rhagic diathesis  exists.  The  time-worn  statement  that  teething 
is  a  normal  process,  and  that  on  that  account  no  surgical  interfer- 
ence should  be  permitted,  does  not  apply  to  the  condition  which 
we  are  considering. 

Nothing  could  be  wider  of  the  mark  than  the  supposition  that 
we  advocate  gum-lancing  at  a  time  when  all  the  parts  involved 
are  in  a  physiological  condition.  Dentition  is  physiological  in 
many  cases  (it  should  be  in  all),  while  in  others  it  begins  and  is 
for  a  time  carried  on  within  the  physiological  range,  gradually 
merging,  however,  into  the  pathological.  When  it  has  reached 
this  condition,  it  is  then  time  to  render  any  surgical  or  medical 
aid  that  may  be  within  our  command.     Again,  there  may  exist  in 


DIFFICULT    DENTITION.  I3I 

the  mouth  an  excessive  yet  physiological  action,  which  in  a  sus- 
ceptible organism  may  be  the  exciting  cause  of  remote  disturb- 
ances, to  be  considered  later.  We  have  mentioned  gum-lancing 
as  one  of  the  first  indications  in  a  severe  case  in  which  the  gums 
are  swollen,  tender,  hot,  and  painful,  and  when  the  eruption  of 
teeth  is  otherwise  shown  by  constitutional  symptoms. 

In  the  operation  of  lancing  the  gums  the  child  should  be  held 
in  the  lap  or  against  the  breast,  and  the  operator  may  then  proceed 
as  he  would  in  operating  upon  the  teeth.  It  does  not  seem  neces- 
sary that  the  head  should  be  held  between  the  knees,  as  is  often 
advocated. 

The  lancet  should  have  only  a  small  cutting  surface,  not  over 
a  quarter  of  an  inch  from  the  point,  this  being  either  straight  or 
curved  in  the  form  of  a  bistoury.  If  the  lancet  used  has  a  long 
cutting  surface,  it  should  be  wrapped  in  linen  or  other  protective, 
and  as  an  additional  precaution  the  finger  should  be  placed  against 
the  blade  at  a  short  distance  from  the  point  to  guard  against  acci- 
dental cutting. 

The  incisions  should  be  made  in  accordance  with  the  object  in 
view,  viz.  to  make  the  cut  directly  over  the  cusps  of  the  advancing 
tooth,  and  of  sufficient  length  and  depth  thoroughly  to  liberate 
them  from  any  pressure  of  the  gum  over  them.  If  one  or  more 
cusps  protrude  through  the  gum,  it  is  not  always  proof  that  there 
is  no  necessity  for  lancing.  An  incision  over  an  incisor  or  cuspid 
should  be  made  to  correspond  with  the  cutting  edge  of  the  tooth; 
while  over  a  molar  there  should  be  made  a  crucial  incision,  thus,  X- 

The  following  quotations  show  the  opinions  of  authorities  in 
regard  to  lancing  the  gums  in  difficult  dentition. 

Dr.  J.  W.  White  says: 

If  these  views  be  correct,  it  is  evident  that  there  may  be  cases  in  which 
a  train  of  morbid  symptoms  is  presented,  ending  possibly  in  convulsions 
and  death,  without  the  existence  of  a  single  local  indication.  It  is  not, 
therefore,  a  sufficient  reason  to  abstain  from  lancing  the  gums,  that  they 
exhibit  neither  tumefaction,  redness,  induration,  nor  the  whiteness  of  the 
presenting  tooth,  though  there  is  generally  some  external  local  manifesta- 
tion. If,  however,  there  be  no  obvious  explanation  for  the  occurrence  of 
untoward  symptoms  during  the  period  of  dentition,  it  seems  the  part  of 
wisdom  to  give  the  child  the  benefit  of  the  doubt  by  free  incisions  over 
the  tooth  whose  eruption  is  in  accordance  with  the  general  laws  to  be 
anticipated,  even  though  there  be  no  hyperemia  of  the  gums;  especially 
as  the  operation  causes  only  a  trifling  amount  of  pain,  inflicts  no  injury, 
and  is  practically  free  from  danger.     Local  indications  demand  the  lancet; 


132  THE    PRACTICE    OF    DENTAL    MEDICINE. 

constitutional  symptoms  of  distress  not  otherwise  accounted  for  suggest 
and  justify  it. 

If  the  positions  assumed  as  to  the  etiology  of  the  morbid  phenomena 
connected  with  dentition  be  correct,  it  follows  that  the  lancing  of  the 
gums  over  the  erupting  tooth  is  the  procedure  which  should  be  promptly 
resorted  to,  as  that  most  essential  and  most  likely  to  afiford  quick  relief; 
unless,  indeed,  it  can  be  shown  that  there  are  valid  objections  to  the  opera- 
tion. The  objection  most  frequently  urged  is  that  unless  the  tooth  is 
erupted  before  there  is  time  for  the  wound  to  heal,  a  cicatricial  tissue  is 
formed  which  offers  increased  resistance.  This  argument  is  in  contraven- 
tion of  recognized  facts  as  to  the  reparative  process.  Cicatricial  tissue  is 
always  of  a  lower  degree  of  organization  than  the  original  structure,  and 
consequently  easier  of  absorption.  The  uniting  medium  in  the  repair  of  a 
solution  of  continuity  possesses  less  vitality,  is  less  perfectly  nourished, 
and  is  easier  of  disintegration  than  the  original  tissue.  The  tendency  of 
scar  tissue  to  break  down  is  a  matter  of  common  observation  even  among 
the  laity,  and  except  in  the  case  of  gum-lancing  is  not  disputed  by  any 
medical  authority.     Gum  tissue  offers  no  exception  to  the  general  rule. 

In  the  proceedings  of  the  Boston  Society  for  Medical  Obser- 
vation the  following  opinions  are  expressed: 

Dr.  Rotch  reported  a  case  of  a  child  nine  months  old  who  had 
had  some  difficulty  in  cutting  the  lower  incisors  at  eight  months. 
The  child  began  to  suffer  from  pain,  was  sleepless,  cried  persist- 
ently, and  had  fever.  Potassium  bromid  and  breast-milk  were 
rejected;  the  temperature  rose  to  104°  F-.,  and  there  was  retention 
of  urine.  After  twenty-four  hours  the  gums,  which  were  swollen 
and  tense,  were  lanced.  Within  two  minutes  after  this  the  child 
fell  asleep  for  twenty  minutes.  Its  temperature  was  then  102°  F. 
After  another  hour  the  temperature  was  normal ;  the  child  nursed, 
and  had  no  further  trouble. 

Dr.  F.  C.  Shattuck  said  that  he  had  never  performed  the  opera- 
tion, never  having  seen  a  case,  either  in  private  practice  or  in  a 
large  dispensary  and  Massachusetts  Hospital  out-patient  expe- 
rience, in  which  it  seemed  to  him  indicated. 

Dr.  Porter  recalled  the  case  of  a  child  who  had  been  in  apparent 
pain  for  forty-eight  hours,  was  restless,  and  would  not  leave  its 
mother's  arms.  The  gums  were  swollen,  so  he  lanced  them  in 
four  places,  and  in  a  few  minutes  the  child  was  asleep.  So  soundly 
did  it  sleep  that  the  mother  was  alarmed,  and  feared  it  was  dead. 
There  was  no  further  trouble  at  that  time.  He  had  always  lanced 
the  gums  of  his  own  children  when  there  was  swelling  and  irrita- 
tion. 

The  subsequent  treatment  should   depend   entirely  upon  the 


DIFFICULT    DENTITION.  I33 

condition  of  the  patient  as  indicated  by  the  symptoms.  If  there 
is  undue  heat  with  tenderness  of  the  gums,  soothing  local  applica- 
tions may  be  found  in  bits  of  ice  placed  in  the  mouth,  or  in  bathing 
the  gums  with  cold  peppermint-water.  Solutions  of  cocain  for 
this  purpose  should  be  used  with  the  greatest  caution. 

It  would  be  quite  impossible  for  such  local  irritation  to  exist 
without  being  recognized  by  the  general  system.  Aside  from 
special  and  well-defined  disturbances  that  may  arise  reflexly,  pro- 
ceeding from  the  dental  irritation,  more  or  less  general  irritability 
may  be  expected,  with  a  possible  rise  in  temperature. 

These  conditions  should  be  met,  usually,  by  sedatives  having 
a  soothing  effect  on  the  entire  nervous  system;  but  all  depends 
upon  the  condition  of  the  patient.  It  is  possible  for  local  and  gen- 
eral irritation  and  pain  to  occur  while  the  system  is  in  the  extreme 
opposite  condition  from  plethora;  indeed,  anemia,  with  adults,  is 
a  common  predisposing  cause  of  neuralgia,  and  under  such  cir- 
cumstances tonics,  not  sedatives,  are  indicated.  For  the  anemia 
some  form  of  iron  may  be  administered.  If  a  scrofulous  diathesis 
exists,  syrup  of  iodid  of  iron,  or  cod-liver  oil,  is  indicated.  If 
there  is  a  plethoric  condition,  sedatives,  and  possibly  antiphlogistic 
remedies,  as  aconite,  should  be  prescribed.  The  writer  prefers 
sodium  bromid  to  the  potassium  salt  and  would  suggest  the  fol- 
lowing as  a  general  sedative  in  the  milder  cases : 

3 — Sodii  bromidi, 

Sodii  bicarb..  aa.  gr.  xvj ; 

Aquse  menth.  pip.,  oj.         ^I. 

Sig. — A  teaspoonful  in  a  wineglassful  of  water  every  two  hours  to  a 
child  from  six  months  to  two  years  old. 

The  condition  of  the  bowels  should  be  noted  and  treated, 
always  keeping  in  mind  the  general  strength  and  vigor  of  the 
patient.  In  a  strong,  vigorous  child,  a  free  movement  of  the  bowels 
should  be  maintained  rather  than  checked;  and  if  constipation 
exists,  a  saline  cathartic  should  be  given.  If  the  condition  of  irri- 
tability is  beyond  the  control  of  ordinary  sedatives,  the  camphor- 
ated tincture  of  opium  is  the  best  remedy  for  children.  If  con- 
vulsions should  occur,  one  effective  remedy  is  the  immersing  of 
the  child  in  as  warm  water  as  can  be  borne,  taking  care  not  to 
have  the  water  too  hot  for  its  delicate  skin.  As  a  medicine,  potas- 
sium bromid  is  the  antispasmodic  remedy;  two  to  five  grains  in 
water  for  a  child  six  months  to  a  year  old. 

Diarrhea    often   accompanies   the   teething   process,    and    the 


134  THE    PRACTICE    OF    DENTAL   MEDICINE. 

treatment  of  diarrhea  should  always  be  governed  by  its  cause  or 
causes,  so  far  as  they  can  be  ascertained. 

We  quote  the  following  from  Dr.  J.  W.  White's  paper  on 
"Diseases  Incident  to  the  First  Dentition" : 

In  all  infants,  especially  in  those  artificially  fed,  there  is  a  tendency  to 
an  acid  fermentation  of  their  food,  due  partly  to  the  character  of  the  food 
and  partly  to  the  peculiar  activity  of  the  mucous  glands,  either  in  response 
to  a  local  irritant  or  to  a  reflex  impression  causing  a  modified  secretion, 
or  to  an  extension  of  a  local  irritation.  Flatulence,  pain,  vomiting,  and 
diarrhea  are  the  natural  results  of  this  condition  of  the  alimentary  tract. 
Attention  to  the  condition  of  the  mouth;  to  the  hygienic  management  of 
the  infant;  and  especially  to  its  diet  as  to  quantity,  quality,  and  frequency, 
should  precede  the  employment  of  drugs.  A  flannel  bandage  around  the 
abdomen  will  serve  as  a  derivative,  and  if  desired,  may  be  made  more 
effective  by  rubbing  powdered  spices  or  dry  mustard  on  the  surface,  or  by 
sprinkling  it  with  turpentine  mixed  with  sweet  oil.  A  change  or  modifica- 
tion of  diet  is  frequently  advisable,  and  a  change  of  air  will  often  act  like  a 
charm.  Under  all  circumstances  it  is  well  to  limit  the  amount  of  food  to 
the  quantity  just  sufficient  to  sustain  life,  in  order  to  afford  the  digestive 
organs  physiological  rest.  The  union  of  an  alkali  with  an  aromatic  is 
indicated,  and  a  grain  of  the  bicarbonate  of  sodium  or  of  potassium  with 
anise,  cinnamon,  or  caraway,  will  prove  of  advantage  if  given  with  each 
meal  until  the  condition  is  corrected. 

If  undigested  food  or  vitiated  secretions  in  the  alimentary  tract  are 
suspected,  a  dose  of  castor-oil  and  aromatic  syrup  of  rhubarb  in  equal 
portions  (a  teaspoonful  of  the  mixture)  will  be  of  great  service.  If  tor- 
pidity of  the  liver  is  diagnosed,  a  few  doses,  at  intervals  of  two  hours,  of 
xV  or  jj  of  a  grain  of  calomel,  with  one  or  two  grains  of  sodium  bicar- 
bonate, will  be  likely  to  correct  the  condition.  If  the  diarrhea  persists  after 
the  action  of  the  purgative,  the  following  prescription  may  be  employed, 
first  prohibiting  the  use  of  any  farinaceous  or  milk  food.  Indeed,  if  all 
food  be  withheld  for  from  two  to  six  or  eight  hours,  and  be  then  given  in 
very  small  quantities,  the  effect  on  the  digestive  tract  will  be  very  beneficial. 

3J — Tinct.  opii,  gtt.  viij ; 

Bismuth,  subnitrat.,  3j; 

Mucilag.  acacias,  §ss; 

Aquae  menth.  pip.,  §jss.         M. 

Sig. — A  teaspoonful  every  three  hours  to  a  child  six  months  old. 

Opium  is  indicated,  however,  only  after  all  offending  matters  have  been 
expelled  from  the  alimentary  canal.  Its  chief  value  then,  is  to  lessen 
peristaltic  action;  but  it  is,  at  best,  a  choice  of  evils  in  the  mal-digestion  of 
infancy,  because  of  its  interference  with  the  normal  secretions  of  the  diges- 
tive fluids.  Opium  is  sometimes  beneficial  when  combined  with  small 
doses  of  a  purgative, — half  a  drop  of  laudanum  to  twenty  or  thirty  drops 
of  a  mixture  in  equal  proportions  of  castor-oil  and  spiced  syrup  of  rhubarb, 
given  three  or  four  times  daily. 


SALIVARY    FISTULA.  135 

Diarrhea  may  be  the  result,  more  or  less  directly,  of  reflex 
nervous  irritation,  and  in  such  cases  the  object  is  to  pacify  the 
nervous  system.  This  condition  is  often  characterized  by  profuse 
watery  stools,  showing  active  fermentation;  deranged  stomach, 
headache,  and  restlessness.  Treatment  of  this  combination  of 
symptoms  is  imperative,  as  it  may  lead  to  cerebral  congestion  and 
convulsions. 

ij — Potassii  bromidi,  5j ; 

Syrupi  simplicis,  Bss; 

Aquae  menthje  pip.,  ojss.         M. 

Sig. — A  half-teaspoonful  in  water  every  hour  or  two. 

If  the  stomach  irritation  is  prominent,  the  above  potassium  salt 
may  not  be  well  borne,  in  which  case  minute  doses  of  sodium 
bromid,  one-half  grain  in  a  little  water  every  fifteen  minutes, 
should  be  substituted. 

Chamomile  is  said  to  have  a  marked  effect  upon  reflex  excita- 
bility, and  it  may  be  administered  in  the  form  of  an  infusion  of  the 
flowers,  one-half  to  one  dram  for  a  child  less  than  one  year  old. 

Constipation  may  coexist  with  teething,  and  when  it  does  the 
treatment  is  quite  as  important  a  matter  as  in  the  opposite  condi- 
tion of  diarrhea.  Suppositories  of  cacao  butter  or  molasses  candy 
may  be  used  with  good  effect  when  it  is  desirable  to  avoid  the 
stomach;  otherwise  castor-oil  and  simple  syrup  in  equal  parts,  with 
the  addition  of  a  drop  or  two  of  the  oil  of  gaultheria,  is  a  good 
remedy.  If  the  constipation  is  persistent,  cod-liver  oil  may  be  ad- 
ministered, beginning  with  the  ten-drop  doses  and  increasing.  If, 
on  the  other  hand,  it  is  temporary,  calomel,  in  doses  of  one-tenth 
of  a  grain,  will  be  effectual. 


CHAPTER    XXV. 

SALIVARY  FISTULA. 


Definition. — A  salivary  fistula  consists  of  an  opening  or  canal 
extending  from  the  outside  of  the  face  to  the  excretory  ducts 
within  the  mouth,  usually  the  duct  of  Stensen. 

Etiology. — The  causes  of  salivary  fistula  are  usually  dependent 
upon  some  traumatic  injury  or  an  abscess,  or  upon  the  result  of 


136  THE    PRACTICE    OF    DENTAL    MEDICINE, 

certain  imperfect  surgical  procedures.  Any  means  whatsoever, 
be  it  surgical  or  the  result  of  an  insidious  and  slowly  progressing 
disease,  which  establishes  a  communication  of  the  ducts  of  the 
mouth  with  the  outside  of  the  face,  is  a  cause  of  salivary  fistula. 

Symptoms. — An  artificial  opening  in  the  face  from  which  issues 
saliva,  at  once  indicates  salivary  fistula.  An  inquiry  into  the  his- 
tory of  the  case  will  reveal  its  origin  as  indicated  under  the  head 
of  etiology.  The  symptoms,  past  and  present,  will  be  governed 
somewhat  by  the  cause.  Certainly  the  condition  is  an  extremely 
uncomfortable  one,  some  of  the  worst  forms  being  those  which 
are  produced  by  sloughing  due  to  ptyalism.  The  loss  of  saliva,  at 
all  times  an  important  if  not  essential  fluid  in  the  human  economy, 
is  a  positive  drain  upon  the  system,  and  may  impair  digestion  and 
otherwise  disturb  the  normal  condition  of  the  mouth.  Therefore 
complications  may  arise,  perhaps  of  an  inflammatory  nature,  which 
will  require  treatment. 

Duration. — Salivary  fistula  may  continue  an  indefinite  length 
of  time  unless  treatment  is  employed  to  prevent  it. 

Treatment. — The  principles  of  treatment  consist  mainly  in 
changing  the  direction  of  the  artificial  orifice  and  in  closing  the 
opening  upon  the  cheek.  When  the  fistula  is  the  result  of  a  recent 
wound,  all  that  is  usually  required  for  this  purpose  is  the  simple 
twisted  suture  and  a  compress  with  a  bandage.  If,  however,  con- 
siderable time  has  elapsed  it  may  be  necessary  to  pare  the  edges 
of  the  opening  in  order  to  place  them  in  a  condition  favorable  to 
healing.  If  the  fistula  is  caused  by  abscess  or  ulceration,  effective 
treatment  may  be  found  in  the  use  of  nitrate  of  silver,  which  may 
be  applied  by  means  of  a  glass  or  silver  probe  on  which  some  of 
the  crystals  are  fused;  this  forms  an  eschar  in  which  granulation 
tissue  springs  up,  and  the  saliva  gradually  finds  its  way  into  the 
natural  channel. 

In  the  more  obstinate  cases  Dr.  Homer  suggests  the  following 
treatment-:  The  head  being  properly  supported,  a  broad  wooden 
spatula  is  introduced  into  the  mouth  opposite  the  site  of  the  fistula, 
and  with  a  large  punch  the  whole  of  the  diseased  structure  is  re- 
moved, and  the  opening  in  the  integument  is  immediately  closed 
with  the  twisted  suture.  In  cases  in  which  the  inner  orifice  of  the 
fistula  is  nearly  obliterated,  Prof.  Gross  suggested  the  use  of  a 
thick,  well-waxed  silk  cord,  passed  through  the  fistula,  brought 
out  at  the  corner  of  the  mouth  and  tied  upon  the  cheek.     When 


SALIVARY    FISTULA.  1 37 

the  opening  into  the  mouth  has  become  re-established,  the  seton 
may  be  removed  and  the  external  wound  closed. 

Dr.  J.  L.  Crouse  has  reported  the  following  case  of  salivary 
fistula,  stating  that  it  was  of  interest  on  account  of  the  operation 
being  different  from  that  usually  mentioned  in  text-books,  and  on 
account  of  its  favorable  result: 

The  patient,  a  girl  of  five  years,  had  injured  herself  four  months  before 
by  falling  upon  a  sharp  piece  of  wood,  which  entered  her  cheek.  The 
greater  part  of  the  foreign  body  was  removed  at  the  time  of  the  injury, 
but  subsequently  several  smaller  pieces  came  away.  The  wound  discharged 
all  the  time,  and  not  seeming  to  get  any  better,  the  mother  brought  the 
patient  to  the  clinic  of  the  Medical  College  of  Ohio.  She  presented,  on 
the  left  cheek,  midway  between  the  angle  of  the  mouth  and  the  concha 
of  the  ear,  a  linear  cicatrix,  vertical  in  direction,  of  one  and  a  half  inches 
in  length.  At  the  upper  border  of  the  same  there  was  a  large  vesicle 
filled  with  turbid  fluid.  This,  the  mother  said,  would  burst  every  now  and 
then,  discharging  the  watery  contents  over  the  cheek.  As  long  as  there 
was  a  free  outlet  to  the  secretions  the  patient  complained  of  no  disagreeable 
symptom,  but  when  the  opening  closed,  then  pain  as  well  as  swelling  of 
the  parotid  region  supervened. 

On  August  4th,  three  months  after  the  injury,  both  ends  of  a  silver 
wire  were  passed  through  the  external  opening  into  the  buccal  cavity;  the 
free  ends  of  the  wire  were  then  twisted  in  the  mouth,  and  the  external 
wound  closed.  The  object  of  the  wire  was  to  maintain  an  opening  between 
the  injured  duct  and  the  buccal  cavity. 

On  September  5th,  thirty-two  days  after  the  operation,  the  wire  was 
removed  and  the  recovery  was  found  to  be  complete. 

Dr.  Henry  Morris  reports  the  treatment  of  a  case  as  follows : 

A  shoemaker  came  under  my  care  in  the  Middlesex  Hospital,  on  June 
24,  1879,  bleeding  from  several  incised  wounds,  one  of  which  was  about 
two  inches  long,  and  vertical  in  direction,  along  the  right  cheek.  On 
June  28th,  saliva  was  seen  trickling  from  the  lower  end  of  this  wound, 
which  was  all  but  healed.  The  patient  now  stated  that  since  the  injury 
the  right  side  of  the  mouth  had  felt  very  hot  and  dry,  and  that  he  had 
constantly  to  moisten  it  by  carrying  the  fluid  from  the  left  over  to  the 
right  side  of  his  mouth.  A  fine  catgut  bougie  was  introduced  at  the 
oral  aperture  of  the  duct,  and  passed  onward  toward  the  parotid  gland 
until  it  emerged  on  the  cheek  through  the  fistula.  The  newly  healed 
wound  was  laid  open,  and  the  proximal  end  of  the  injured  salivary  duct 
searched  for,  and  found  by  squeezing  the  parotid  gland  until  a  little  saliva 
was  forced  out  of  the  duct.  Into  this  the  point  of  the  bougie  was  inserted 
and  pushed  onward  for  about  half  an  inch.  The  edges  of  the  wound  were 
brought  together  with  three  hare-lip  pins  and  twisted  sutures,  and  the 
bougie  cut  short,  so  that  the  short  end,  not  long  enough  to  be  caught 
between  the  molar  teeth,  was  left  protruding  into  the  mouth  from  the  slit- 
like orifice  of  the  duct.     The  patient  at  once  appreciated  a  marked  differ- 


138  THE    PRACTICE    OF    DENTAL   MEDICINE. 

ence  in  the  feeling  of  the  right  side  of  the  mouth,  which  was  now  in  all 
respects  like  the  other  side,  and  he  could  distinctly  feel  saliva  trickling  into 
it.  On  July  4th  the  bougie  came  away  accidentally.  The  wound  on  the 
cheek  had  been  all  but  healed  for  four  days,  but  a  little  discharge  still 
escaped  at  its  lower  end.  On  July  9th  a  little  saliva  was  still  escaping; 
cotton  wool  and  collodion  were  therefore  applied  over  the  wound  until 
July  15th.  By  this  date  the  wound  was  securely  healed  and  all  the  saliva 
flowed  freely  into  the  mouth.  The  man  was  retained  in  the  hospital  for  a 
few  days  longer,  and  was  then  discharged  well. 


CHAPTER    XXVI. 

SALIVATION. 

Definition. — An  abnormally  excessive  secretion  of  saliva  caused 
by  some  agent  acting  either  locally  or  systemically. 

Synonyms. — Ptyalism;  Ptyalismus  acutus  sympatheticus; 
Mouth-watering. 

Etiology. — One  form  of  excessive  secretion  of  saliva  may  be 
caused  by  the  sight,  smell,  or  thought  of  appetizing  food.  This 
is  purely  physiological ;  also  the  condition  in  which  there  is  supera- 
bundant salivary  secretion  in  young  people  and  children,  the  result 
of  hereditary  tendencies  or  the  normal  teething  process,  has  no 
pathological  significance. 

Salivation  which  is  the  result  of  some  pathological  action  may 
be  seen  in  connection  with  inflammations  of  the  oral  mucous 
membrane,  as  in  ulcerative,  aphthous,  catarrhal,  or  mercurial 
stomatitis.  Salivation  also  takes  place  during  certain  stages  of 
such  diseases  as  dengue,  parotitis,  smallpox,  scurvy,  hysteria,  and 
hydrophobia;  it  ma}^  also  take  place  during  dentition  and  preg- 
nancy. 

Of  medicines  which  increase  the  flow  of  saliva,  mercury  is  the 
one  which  takes  nearly  all  the  blame.  Other  preparations  have  a 
similar  action,  such  as  copper,  lead,  gold,  antimony,  bismuth, 
potassium  iodid,  arsenic,  castor-oil,  pilocarpin,  and  iodin. 

Pathology. — In  severe  cases  there  are  always  accompanying 
local  changes  from  the  normal  to  pathological  conditions,  as  indi- 
cated by  pericementitis  or  gingivitis  with  its  various  stages  from 


SALIVATION.  139 

sponginess  of  the  gums  to  ulceration  and  sloughing.  The  pres- 
ence of  stomatitis  indicates  a  spreading  of  the  effects  to  other  parts, 
and  a  more  general  disturbance. 

Symptoms. — The  increased  flow  of  saliva  is  naturally  taken  as 
the  one  characteristic  symptom;  there  is  also  to  be  noted  a  cop- 
pery taste  in  the  mouth,  followed  by  swelling  and  tenderness  of 
the  gums.  The  breath  soon  becomes  fetid,  and  the  teeth  become 
loose.  The  tongue,  as  the  pathological  condition  advances,  be- 
comes large  and  flabby,  covered  with  indentations  at  its  sides 
corresponding  to  the  spaces  between  the  teeth.  The  teeth  are 
hypersensitive  to  percussion,  and  the  simple  gingivitis  which 
occurred  at  first  may  go  on  to  extensive  swelling  and  ulceration, 
and  even  gangrene.  The  face  and  neck  may  become  swollen,  and 
the  glands  in  this  vicinity  inflamed,  tense,  and  tender  through 
septic  absorption.  The  swelling  and  tenderness  prevent  opening 
of  the  mouth,  deglutition,  and  speech.  It  should  not  be  sur- 
prising to  note  that  the  entire  system  sympathizes  with  this  condi- 
tion, as  indicated  by  heat  of  the  skin,  quickened  pulse,  thirst  and 
loss  of  appetite. 

The  duration  of  this  condition  varies  to  a  great  extent,  depend- 
ing much  upon  the  peculiarities  of  constitution  in  different  indi- 
viduals. With  some  patients  it  may  last  only  a  few  days,  while 
in  others  the  time  may  be  extended  for  months  after  the  primary 
cause  has  been  removed. 

Treatment. — Mild  cases  may  need  no  special  treatment,  as  they 
get  well  in  a  few  days  after  the  mercury  or  other  cause  has  been 
discontinued.  In  severe  cases  treatment  is  demanded,  for  there 
may  be  severe  pain  which  must  be  relieved  by  some  anodyne, — as, 
for  instance,  ten  drops  of  deodorized  tincture  of  opium  in  water 
every  half-hour  till  relief  is  afforded,  or  until  three  doses  have  been 
taken;  after  which  an  interval  of  three  or  four  hours  should  elapse 
before  the  administration  is  continued.  As  an  internal  corrective 
of  salivation,  potassium  chlorate  may  be  administered  in  doses  of 
five  to  fifteen  grains  three  times  daily,  dissolved  in  a  liberal  quan- 
tity of  water  or  lemonade.  This  remedy  may  be  useful  also  as  a 
wash,  locally;  one  or  two  drams  being  dissolved  in  a  pint  of  water, 
and  used  every  three  hours.  It  may  be  noted  here  that  potassium 
chlorate  is  not  without  poisonous  effects,  as  well  as  the  fact  that 
many  of  its  alleged  therapeutic  qualities  have  been  seriously  ques- 
tioned in  recent  years. 


140  THE    PRACTICE    OF    DENTAL    MEDICINE. 

If  there  is  much  inflammation,  non-irritating  warm  douches 
should  be  used;  later,  when  the  severe  symptoms  have  subsided, 
applications  more  decidedly  astringent  may  be  employed.  For 
this  purpose  one  of  the  best  is  Goulard's  extract  (liquor  plumbi 
subacetatis).*  One  dram  of  this  may  be  added  to  eight  ounces  of 
water,  and  applied  every  two  hours.  The  following  prescription 
will  be  found  useful : 

^ — Aquae,  Bxv ; 

Tinct.  catechu,  oj ; 

Aluminis,  oij.         M. 
Sig. — Mouth-wash. 

Also  an  excellent  mouth-wash,  possessing  antiseptic  qualities 
as  well  as  a  mild  astringent  effect,  is  the  following  prescription, 
formulated  over  fifteen  years  ago: 

5 — Acid,  carbolici  (Calvert's  No.  i),       gtt.  xv; 
Olei  gaultheriae,  gtt.  ij ; 

Aquse,  oiijss; 

Tinct.  cardamomi  comp.,  3iv.         M. 

Sig. — Mouth-wash.     Rinse  the  mouth  four  times  daily. 

Ulcerated  spots  may  be  touched  with  trichloracetic  acid,  or 
nitrate  of  silver,  using  a  finely  pointed  glass  tube.  It  may  be  well 
to  administer  some  cooling  laxative,  such  as  a  Seidlitz  powder  or 
magnesium  sulfate. 


CHAPTER    XXVII. 

RANULA. 

Definition. — Ranula  is  a  peculiar  form  of  tumor  having  its 
origin  under  the  tongue  and  caused  by  obstruction  to  the  flow 
of  saliva,  or  mucus  from  the  glands  beneath  the  tongue.  The  term 
ranula  may  include  several  other  forms  of  sublingual  swelling. 

Etiology. — Many  cases  of  ranula  occur  in  young  people  from 
fifteen  to  thirty  years  of  age,  yet,  as  congenital  cases  have  been 
reported,  and  also  instances  occurring  in  older  people,  we  are 
hardly  justified  in  designating  age  as  a  causative  agency.  In 
tracing  the  steps  by  which  a  ranula  is  formed,  we  first  notice  the 
condition,  which  is  essentially  that  of  an  encysted  tumor.  Now, 
in  order  that  this  tumor  may  be  formed  there  must  be  an  obstruc- 

*  It  discolors  the  teeth  temporarily,  but  is  without  permanent  injury. 


RANULA.  141 

tion  in  the  canals  or  orifices  of  the  excretory  cUicts  leading  from 
the  glands.  There  may  be  an  inflammatory  adhesion,  or  gluing 
together  of  the  walls ;  or  some  substance  may  obstruct  the  free  flow 
of  secretion,  which  accumulates,  causing  absorption  by  pressure, 
as  well  as  dilatation  of  its  walls,  until  a  tumor  is  formed  possessing 
properties  as  described. 

This  obstruction  may  occur  in  minute  follicles  or  conglobate 
glands,  or  it  may  take  place  in  the  duct  of  Wharton  or  other  larger 
ducts;  or  it  may,  according  to  Fox,  depend  upon  an  inflammation 
of  the  bursa  which  is  placed  between  the  genio-hyoglossi  muscles. 
Again,  cysts  such  as  we  have  just  described  may  form  in  the 
mucous  membrane  of  the  lips  or  cheeks,  or  in  mucous  surfaces  in 
other  parts  of  the  body. 

Pathology. — As  a  matter  of  observation,  the  sublingual  gland 
is  rarely  the  subject  of  calcareous  formations.  Prof.  Gross  met 
with  only  one  such  concretion,  which  he  removed  from  a  man 
fifty-four  years  of  age.  The  concretion  caused  for  several  weeks 
severe  local  distress,  attended  with  great  difficulty  in  moving  the 
tongue. 

Pare  describes  a  case  of  ranula  in  which  there  were  five  con- 
cretions, the  largest  of  which  was  the  size  of  an  almond,  causing  a 
large  abscess  under  the  tongue.  Whether  the  obstruction  occurs 
from  inflanmiatory  adhesions  or  from  adventitious  substances 
within  the  canals,  there  is,  in  the  course  of  time,  enlargement  of 
bloodvessels,  absorption  of  the  walls  of  ducts,  and  swelling.  The 
contents  which  have  accumulated  may  be  of  a  thin  consistence, 
very  like  the  secretion  itself,  or  they  may  be  thick  and  cheesv. 

Symptoms. — The  symptom  first  attracting  attention  is  a  swell- 
ing in  the  vicinity  of  the  lower  jaw,  which  may  show  externally; 
indeed,  in  some  cases  the  swelling  may  rapidly  extend  down  the 
neck  to  the  clavicle,  and  alarming  symptoms,  such  as  fever  and 
obstructed  breathing,  may  arise,  which  will  require  immediate  and 
radical  treatment.  In  ordinary  cases  the  swelling  seldom  exceeds 
the  size  of  a  pigeon's  egg,  and  may  usually  be  found  either  on  the 
side  of  the  tongue  or  beneath  it. 

The  onward  progress  of  the  condition  called  ranula  is  usually 
slow,  and  causes  little  or  no  suffering;  therefore  it  does  not  usually 
affect  the  general  health.  In  some  cases  a  ranula  may  be  years  in 
developing,  and  in  others  a  serious  condition  may  arise  in  a  few 
hours;  all  depending  upon  the  cause,  or  upon  the  general  condition 
of  the  patient. 


142  THE    PRACTICE    OF    DENTAL    MEDICINE. 

Prognosis. — The  prognosis  is  generally  favorable,  if  correct 
treatment  is  employed. 

Diagnosis. — Ranula  may  be  distinguished  from  other  tumors 
by  its  location,  its  grayish,  translucent  aspect,  not  unlike  the  belly 
of  a  frog  (whence  its  name),  its  irregular  oval  shape,  and  the  fact 
that  its  contents  upon  puncture  are  of  a  glairy,  ropy  consistence, 
like  the  white  of  egg;  bearing  in  mind  that  in  cases  of  long  stand- 
ing the  contents  may  vary  from  the  above-described  consistence 
and  color  to  a  substance  of  a  yellow,  oily  nature,  often  thick  and 
cheesy.  Sometimes  gritty  particles,  concretions  of  the  phosphate 
and  carbonate  of  lime,  are  found. 

Treatment. — There  are  varying  circumstances  which  should 
govern  the  treatment  of  ranula;  for  instance,  the  age,  size,  and 
consistence  of  the  tumor.  In  mild  and  recent  cases  the  most  satis- 
factory results  are  obtained  by  excision  of  a  portion  of  the  sac,  in 
the  form  of  an  oval  flap,  and  the  brushing  of  the  surfaces  with 
tincture  of  iodin,  full  strength.  The  wound  suppurates,  and  soon 
heals  by  the  granulation  process.  In  some  cases  the  seton  is 
effectual,  and  in  others  the  injection  of  tincture  of  iodin  is  suffi- 
cient. The  injection  of  two  drops  of  deliquescent  zinc  chlorid 
into  the  sac  has  been  recommended,  but  it  has  also  met  with  objec- 
tions on  account  of  the  very  severe  pain  which  it  produces,  as  well 
as  the  frequent  lack  of  success  in  its  use. 

A  modified  seton  may  be  employed  in  the  following  way: 
Thread  a  curved  needle  with  black  iron-dyed  silk,  a  double  thread, 
and  having  passed  the  needle  through  the  cyst,  remove  it  and  tie 
the  ends  of  the  thread  so  that  a  loop  projects  sufficiently  to  enable 
the  operator  to  move  the  thread  back  and  forth  every  other  day, 
till  there  is  no  discharge.  The  thread  may  be  then  removed  and 
the  openings  allowed  to  close  by  the  granulation  process. 

When  the  tumor  is  large  and  its  contents  are  hard,  extirpation 
of  the  whole  mass  is  necessary.  An  incision  may  be  made  along 
the  side  of  the  tongue,  and  the  flaps  of  mucous  membrane  turned 
aside,  when,  with  the  handle  of  the  scalpel,  the  mass  may  usually 
be  turned  out. 

Dr.  T.  F.  Prewitt  described  a  case  before  the  American  Medical 
Association  as  follows: 

G.  M.,  aged  fifteen,  presented  himself  on  May  6,  1882,  having  a  swelHng 
under  the  left  lower  maxilla,  nearly  as  large  as  a  goose-egg.  It  fluctuated 
freely,  some  portions  of  it  seeming  hard,  however,  and  projected  also  into 
the  mouth  under  the  tongue,  though  the  swelling  here  was  not  very  great. 


RANULA.  143 

A  diagnosis  of  ranula  was  made,  and  a  portion  of  the  cyst-wall  in  the  floor 
of  the  mouth  was  excised.  A  quantity  of  clear,  transparent  mucoid  fluid 
escaped,  spurting  out  several  feet  as  the  cyst  was  excised.  In  the  course  of 
two  or  three  weeks  this  had  contracted,  and  threatened  to  close,  when 
catheterization  was  resorted  to. 

In  the  meantime  a  ranula  had  appeared  under  the  tongue  upon  the 
right  side,  with  translucent,  bluish,  thin  walls,  but  not  projecting  beneath 
the  jaw;  this  also  was  treated  by  excision  of  a  portion  of  the  cyst-wall.  In 
July  the  young  man  ceased  to  present  himself;  the  orifice  closed,  the  sacs 
rapidly  filled,  and  Dr.  L.  again  brought  him  to  me  in  an  alarming  state 
from  threatened  suffocation.  Both  ranulae  were  swollen  and  painful.  Upon 
the  left  side  the  swelling  extended  well  down  toward  the  clavicle  and 
sternum,  and  across  the  trachea  in  front.  Upon  the  right  side  the  ranula 
was  greatly  swollen,  meeting  that  upon  the  left  side  under  the  chin  in  a 
continuous  swelling.  Both  inspiration  and  expiration  were  obstructed; 
the  young  man  was  flushed  and  feverish.  From  the  rapidity  of  the  occur- 
rence of  the  symptoms  and  their  increasing  gravity  it  seemed  as  though 
tracheotomy  might  be  necessary.  I  incised  the  cysts  freely,  permitting  the 
free  escape  of  the  accumulated  fluids,  and  directed  hot  fomentations  to  be 
persistently  applied.  This  gave  speedy  relief  to  all  urgent  symptoms.  As 
contraction  took  place  I  again  resorted  to  catheterization,  with  the  view  of 
preventing  reclosure.  .  This  was  persevered  in  for  two  or  three  months,  and 
was  more  effectual  upon  the  left  side,  for  the  reason  that  the  bougie,  a  soft, 
conical  rubber,  about  15  French,  could  be  passed  down  for  two  inches  and 
could  be  felt  below  the  margin  of  the  jaw. 

Upon  the  right  side  a  probe  only  could  be  used,  and  when  its  use  was 
intermitted  for  a  few  days  the  opening  would  close  completely.  I  deter- 
mined, therefore,  to  make  a  permanent  opening  by  a  plastic  operation  upon 
that  side.  Carefully  dissecting  off  the  mucous  membrane  of  the  mouth  over 
the  cyst,  denuding  a  surface  as  large  as  a  nickel,  I  then  incised  the  cyst- 
wall,  turned  it  over,  and  tacked  its  free  edge  to  the  border  of  the  mucous 
membrane  of  the  mouth  with  fine  silk  sutures,  thus,  as  it  were,  binding  the 
opening  in  the  cyst  with  mucous  membrane,  and  interposing  an  effectual 
safeguard  against  its  closure.  Union  by  first  intention  took  place,  the 
stitches  were  removed  on  the  third  day,  and  an  orifice  was  secured  that  has 
remained  patulous  to  this  time. 

Dr.  C.  Lovegrove  recommends  the  following  treatment  in  some 
cases  of  ranula :  Pass  a  tenaculum  through  the  base  of  the  tumor 
and  draw  the  part  somewhat  forward.  After  withdrawing  the 
thicker  part  of  the  tenaculum  a  little,  pass  a  plain  gold  ring,  such 
as  is  used  when  the  ears  are  first  pierced,  by  the  side  of  the  tenacu- 
lum through  both  holes;  then  clasp  it  securely,  and  leave  in  situ 
for  three  or  four  weeks;  then  remove.  A  permanent  exit  for  the 
mucus,  etc.,  will  then  remain,  and  all  trouble  will  cease.* 

*  A  description  of  a  large  ranula,  accompanied  by  a  tumor  of  a  different 
character,  is  described  in  the  Dental  Cosmos  for  July  1S81,  page  389. 


144  THE    PRACTICE    OF    DENTAL    MEDICINE. 


LOCAL  DISEASES  AFFECTING  THE  DENTAL  AND 
SURROUNDING  BONY  TISSUES. 


CHAPTER    XXVIII. 

DENTAL  CARIES. 

Synonyms. — Caries;  Decay. 

Etiology. — Prof.  Miller  notes  the  following  causes  to  which,  at 
different  times,  decay  of  the  teeth  has  been  ascribed:  Depraved 
juices  in  contact  with  the  teeth.  Disturbances  of  nutrition.  In- 
flammation. Worms.  Putrefaction.  Chemical  dissolution. 
Parasites.  Electrolytic  decomposition.  Chemico-parasitic  influ- 
ences.    Diverse  causes. 

Hippocrates  wrote  of  the  first  of  the  above-named  causes  as 
early  as  456  B.  C.  Similar  explanations  of  caries  were  given  by 
Krautermann  in  1732,  Bourdet  in  1757,  Benj.  Bell  in  1787,  and 
Kappis  in  1794. 

For  further  data  in  relation  to  these  different  causes,  the  reader 
is  referred  to  Dr.  Miller's  work  on  "Micro-Organisms  of  the 
Human  Mouth,"  page  120  et  seq. 

The  essential  factors  concerned  in  decay  of  the  teeth  may  be 
named  under  three  heads,  viz. :  i.  A  defect  in  the  tooth-structure. 
2.  A  decomposable  substance.     3.  Bacteria. 

The  defect  in  the  tooth-structure  may  have  its  origin  in  a  con- 
genital condition  or  it  may  be  due  to  some  accident  by  which  the 
tooth  is  scratched  or  broken,  or  to  the  corrosive  action  of  ferment- 
producing  organisms,  favored  by  irregularity  and  crowding  of 
the  teeth.  When  once  the  smooth  surface  of  the  enamel  is  broken, 
the  defective  place  affords  lodgment  for  food  and  secretions  of  the 
mouth;  this,  aided  by  lactic-acid-producing  bacteria,'^  which  are 

*  Organisms  which,  in  the  presence  of  starches  and  sugars,  cause  a  fer- 
ment and  produce  lactic  acid,  which  decalcifies  the  enamel  and  dentin. 
Since  Dn  Miller's  investigations,  Galippe  and  Vignal  have  succeeded  in 
isolating  six  different  kinds  of  acid-forming  organisms  from  the  decay  of 
teeth.  Prof.  Jung,  of  the  University  of  Berlin,  has,  by  using  solid  media 
which  permitted  treatment  at  the  temperature  of  the  mouth-cavity,  suc- 
ceeded in  isolating  ten  different  kinds  from  dental  decay.  We  may  con- 
sider it  settled  that  the  decay  of  teeth  is  not  due  to  a  specific  bacterium. 


DENTAL    CARIES.  I45 

ever  present  in  the  mouth,  makes  the  breach  larger,  and  they  feed 
upon  the  decomposing  material. 

Thus  we  have  what  might  essentially  be  termed  a  chemico- 
parasitic  process,  although  the  starting-point  may  be  the  result 
of  a  mechanical  action.  The  principal  factor  is  the  lactic  acid, 
which  is  formed  by  the  action  of  organisms  upon  starchy  and  sac- 
charine substances,  and  which  finds  its  way  into  crevices  and 
spaces  between  the  teeth.  Other  acids  may  be  present  in  the 
mouth  and  assist  in  the  decalcifying  action  on  the  teeth;  for  in- 
stance, acid  fruits,  as  lemons  and  grape-fruit;  the  drink  known  as 
acid  phosphate;  the  acid  contained  in  medicines,  or  that  in  the 
saliva  as  the  result  of  certain  diseases,  such  as  rheumatism,  gout, 
various  forms  of  dyspepsia,  etc. 

When  the  dentin  is  reached,  on  account  of  its  canals  the  pro- 
cess of  dissolution  by  bacteiia  goes  on  much  more  rapidly  than 
the  decalcification  of  the  enamel,  which  is  a  solid  substance. 
After  decalcification  by  the  acid,  the  albuminous  basic  substance 
of  the  dentin  is  dissolved  by  micro-organisms  which,  according 
to  Miller,  have  the  power  of  peptonizing  or  converting  it  into  a 
soluble  modification.  Again,  there  are  also  bacteria  which  have 
both  the  powers  above  named;  they  may,  by  means  of  acid-pro- 
duction, act  in  the  first  stages  of  decay,  and  at  the  same  time  play 
a  part  in  the  dissolution  of  the  dentin.* 

Predisposing  Causes. — The  character  of  the  "tooth-struc- 
ture" has  always  been  considered  an  important  element  in  the 
action  of  dental  caries.  Although  the  subject  is  imperfectly  under- 
stood at  the  present  time,  it  is  thought  that  the  vital  resistance  to 
caries  is  alike  important  .with  density  of  tooth-structure.  We  may 
well  believe  that  in  vigorous  health  the  organic  structure  of  the 
dentin  is  supplied  with  a  material  endowed  with  increased  vitality 
and  power  to  resist  decay.  The  oral  fluids,  etc.,  constituting  the 
environment  of  the  teeth,  must,  in  a  condition  of  health,  be  less 
favorable  to  the  progress  of  decay.  The  position  of  the  teeth, 
including  the  relation  they  bear  to  one  another,  is  also  an  impor- 
tant element.  A  crowded  condition  of  the  teeth,  affording  lodg- 
ment for  substances  which  are  not  easily  removed,  favors  the 
carious  process.     Deep  fissures,  in  the  molars  especially,  promote 

*  For  a  more  extended  reading  in  regard  to  the  action  of  acids  and  for 
description  of  micro-organisms,  see  Dr.  Miller's  book  on  "Micro-organisms 
of  the  Human  Mouth,"  pages  212-215. 

II 


146  THE    PRACTICE    OF    DENTAL   MEDICINE. 

decay  by  reason  of  their  capacity  for  the  retention  of  organisms 
and  food  particles  which  are  forced  into  them  by  the  power  of 
mastication.  A  "pocket"  in  the  gum  at  the  neck  of  the  tooth  will 
hold  organisms  and  fermentable  substances,  and  furnish  all  the 
essentials  of  decay. 

During  pregnancy  there  is  often  increased  acidity,  as  well  as 
an  extra  demand  upon  nutrition.  The  teeth  are  frequently  neg- 
lected at  this  time.  Pregnancy,  however,  is  followed  by  a  far 
more  important  period,  lactation,  when  the  drain  upon  nutrition 
and  all  the  vital  forces  is  indeed  great.  Heredity  undoubtedly 
influences  the  type  of  the  tooth,  its  regularity,  structure,  etc.,  and 
is  one  of  the  important  factors  concerned  in  dental  caries. 

General  diseases,  by  lowering  the  vitality  and  nutritive  supply, 
with  resulting  vitiated  secretions,  must  be  considered  as  con- 
comitant causes  of  decay. 

Pathology. — It  has  been  thought  that  there  must  be  first  some 
defect  or  fissure  in  the  surface  of  the  tooth,  for  the  conditions 
upon  which  this  process  depends  are  not  found  on  a  perfectly  clean 
surface,  but  Dr.  J.  Leon  Williams,  of  London,  has  demonstrated 
that  over  certain  surfaces  of  the  enamel  there  is  often  a  hardened 
film,  filled  with  organisms.  These,  the  caries  fungi,  excrete,  in 
the  presence  of  sugar  and  starches,  lactic  acid,  which  slowly  decal- 
cifies the  enamel,  dissolving  first  the  cement  substance  around 
the  enamel  rods,  and  afterward  the  rods  themselves.  Before 
the  enamel  breaks  away,  the  dentin  within  is  deeply  decalcified, 
and  decay  results. 

The  direction  of  the  destructive  process  when  once  begun  is 
that  of  the  dentinal  canals,  although  there  are  cases  in  which,  by 
anastomosing  canals,  the  carious  process  spreads  laterally. 

The  color  of  these  affected  structures  varies  with  the  rapidity 
of  the  carious  process.  At  first  it  is  white,  and  in  rapid  decay 
remains  so  in  a  degree  proportionate  to  the  rapidity,  but  if  the 
decay  goes  on. slowly  the  superficial  layer  becomes  stained  by  long 
exposure.  This  protects  the  deeper  structures  by  preventing  the 
entrance  of  those  agents  upon  which  caries  depends,  and  not  infre- 
quently arrests  decay.  In  the  carious  process,  various  grades  of 
tooth-destruction  may  thus  be  seen  at  different  points.  A  cavity 
which  has  been  formed  is  evidence  that  complete  destruction  has 
taken  place  at  that  point,  beyond  which  may  be  found  different 
degrees  of  softening,  and  lastly,  a  zone  of  partially  softened  dentin 
lighter  in  color,  which  adjoins  the  normal  structure. 


DENTAL    CARIES. 


147 


Dr.  R.  R.  Andrews  has  kindly  furnished  the  accompanying 
specimens  illustrative  of  dental  caries. 

Fig.  10. 


Normal  dentin.    Longitudinal  section,  showing  canals.     (Dr.  Andrews. 

Fig.  II. 


^i^ 


Normal  dentin.    Cross  section,  show  ing  canals.     (Dr.  Andrews.") 

Dr.  Black,  in  the  "American  System  of  Dentistry,"  says: 


148 


THE    PRACTICE    OF   DENTAL   MEDICINE. 


The  penetration  of  enamel  is  distinctly  different  from  the  penetrating  of 
dentin.     This  substance  has  not  the  natural  openings  that  are  characteristic 

Fig.  12. 


Natural  decay  of  a  human  tooth.     I,oiiL;iu 
Miller.) 


ion,  showing  distended  canals.    (Prof. 


Fig.  13. 


Dental  caries.    Showing  a  cavity  formed.     (Dr.  Andrews.) 

of  the  dentin,  and  therefore  does  not  present  the  same  opportunities  for 
growth  of  the  fungus  within  its  structure.     It  has  been  held  by  most  of 


DENTAL    CARIES. 


149 


those  who   have   written   on  this   subject  that  the   fungus   is.  incapable   of 
attacking  enamel.     If  by  the  term  "attack"  is  meant  an  invasion,  or  growth, 

Fig.  14. 


Human  dentin.    Showing  organisms  of  decay.     (Prof.  Miller.) 

Fig.  15. 


Cross  section  of  infected  human  tooth.    Natural  decay.     (Prof.  Miller.) 

of  the  fungus  into  the  substance  of  the  enamel,  this  view  is  correct.     No 
signs  of  the  fungus  are  to  be  found  in  the  enamel  until  after  it  has  become 


150 


THE    PRACTICE    OF    DENTAL   MEDICINE. 


SO  far  disorganized  that  its  crystals  are  loosened  and  begin  to  fall  apart. 
Except  that  of  localization,  and  in  some  cases  discoloration,  the  softening 

Fig.  1 6. 


Dental  caries.    Micro-organisms  working  through  the  "  granular  layer"  of  Tomes.    (Prof. 
Miller.) 

Fig.  17. 


Organisms  of  dental  caries.    (Prof.  Miller.) 

of  the  enamel  in  the  first  stages  of  caries  presents  no  other  phenomena  than 
those  produced  on  that  substance  by  acid  action  outside  of  the  mouth.     In 


DENTAL    CARIES.  I5I 

case  this  effect  is  rapid  the  enamel  is  seen  to  lose  its  transparency,  and  soon 
its  prisms  show  a  disposition  to  fall  apart  in  such  a  way  as  to  give  the  im- 
pression that  they  have  been  separated  the  one  from  the  other.  This  disin- 
tegrated material  is  easily  removed  from  the  surface  in  the  form  of  fane 
dust,  and  upon  microscopic  examination  is  found  to  be  composed  of  short 
lengths  of  enamel  rods.  It  seems  that  the  acid  [lactic]  has  the  effect  of 
dissolving  the  connecting  substance  which  unites  these  into  a  compact  mass, 
and  that  the  rods  themselves  are  dissolved  more  slowly.  Thus  the  enamel 
fast  becomes  more  porous^  and  finally  some  of  the  rods  fall  away,  leaving 
minute  openings  through  its  substance  by  way  of  which  the  fungi  of  caries 
are  admitted  to  the  dentin  beneath.  On  the  proximal  surfaces  of  the  teeth, 
near  the  point  of  contact,  a  portion  thus  softened  may  frequently  be  found; 
this  may  be  brushed  away  and  the  surface  again  polished,  and  show  no 
opening  exposing  the  dentin.  Other  cases  may  on  careful  investigation 
show  one  or  several  openings  of  minute  size  through  which  the  dentin  is 
exposed.  After  such  exposure  the  enamel  is  undermined  by  the  more 
rapid  softening  of  the  dentin  which  extends  laterally  under  it.  This  disin- 
tegration presents  precisely  the  same  characteristics  as  that  occurring  on 
the  outer  surface.  In  this  way  the  enamel  is  gradually  destroyed  through  its 
entire  thickness;  or,  more  often,  by  the  rapid  disintegration  of  the  dentin 
beneath  is  weakened  and  left  unsupported,  and  breaks  away,  leaving  the 
opening  into  the  cavity  jagged  and  irregular.  In  many  instances  of  very 
rapid  decay,  hoAvever,  especially  if  the  enamel  be  very  thick  and  strong, 
the  carious  process  will  extend  to  a  considerable  distance  under  it  laterally 
before  breakage  occurs;  and  in  this  case  the  opening  may  be  so  small  that 
the  cavity  might  escape  detection  but  for  a  slight  discoloration  which  is 
seen  through  the  enamel. 

Treatment. — The  treatment  of  dental  caries  may  be  classed 
under  two  heads, — medical  and  surgical;  although  very  nearly  all 
treatment  at  present  is  surgical.  This  does  not  deny  that  a  great 
deal  may  be  done  with  medical  preparations,  and  with  antiseptics 
together  with  proper  food  as  a  prophylactic  measure,  to  which  we 
may  at  this  point  give  some  attention. 

It  is  generally  conceded  that  the  nutritive  process  extends 
into  the  structure  of  the  teeth;  and  that  hygiene  thoroughly  fol- 
lowed in  all  that  the  term  includes  will  so  improve  assimilation  that 
ordinary  nutritious  food  will  furnish  materials  to  make  good  tooth- 
structure  and  vitality,  and  does  do  so.  Such  food  consists  mainly 
of  fish,  eggs,  meats,  Graham  bread,  oatmeal,  milk,  and  butter. 
Dr.  Miller  emphasizes  the  need  of  food  which  is  sufficiently  hard  to 
give  the  teeth  exercise,  and  of  that  which  does  not  readily  undergo 
acid  fermentation  in  the  mouth. 

Inasmuch  as  micro-organisms  play  so  important  a  part  in 
dental  caries,  it  is  evident  that  whatever  restricts  or  destroys  these 


152  THE    PRACTICE    OF    DENTAL   MEDICINE. 

organisms  will  proportionately  lessen  the  tendency  to  decay.  Un- 
fortunately this  means  is  limited  in  its  action  to  prevent  decay,  and 
much  more  so  in  its  power  to  arrest  it.  For  instance,  an  anti- 
septic mouth-wash  cleanses  the  mouth,  and  undoubtedly  lessens 
the  activity  of  bacteria,  but  such  liquids  cannot  be  carried  into 
cavities  or  between  the  teeth  so  as  to  reach  all  parts  affected. 
Moreover,  the  strength  of  all  antiseptics  must  be  limited  so  that 
no  injurious  action  may  ensue,  and  with  this  limitation  it  is  impos- 
sible to  penetrate  softened  tooth-structure  and  destroy  all  bacteria. 
Nevertheless,  antiseptic  mouth-washes  are  to  be  strongly  com- 
mended, not  only  for  their  germicidal  power  and  cleansing  prop- 
erties but  for  their  beneficial  action  on  the  soft  tissues.  Chewing- 
gum  is  to  be  commended  in  moderation  for  the  cleansing  and 
exercise  it  gives  the  teeth,  the  stimulation  of  the  salivary  glands 
and  the  aid  thus  given  to  digestion. 

We  have  spoken  of  germicides  and  their  effect  on  dental  caries, 
but  it  is  important  to  note  also  the  good  effect  of  alkaline  washes 
which  neutralize  acids,  thus  preventing  their  action  on  the  teeth. 
"Alilk  of  magnesia"  is  an  alkaline  liquid  which  forms  a  coating  on 
the  teeth,  and  is  one  of  the  best  alkaline  washes  for  this  purpose. 
It  was  introduced  to  the  profession  by  Dr.  E.  C.  Kirk,  of  Phila- 
delphia. 

As  a  means  of  arresting  decay  at  any  stage,  no  local  treatment 
is  so  efficient  as  the  application  of  silver  nitrate  to  the  decayed 
surface  by  means  of  a  glass  rod  on  which  a  few  of  the  crystals  have 
been  fused,  or  that  of  dipping  a  suitably  pointed  orange-wood 
stick  into  the  powdered  crystals  and  applying  in  the  same  way. 
The  excess  of  saliva  should  be  wiped  from  the  surface  to  which  the 
application  is  to  be  made,  and  the  soft  tissues  of  the  mouth  pro- 
tected by  rubber  dam  or  lintine. 

Of  internal  treatment  there  is  little  to  be  said.  The  syrup  of 
the  hypophosphites  of  lime  and  soda  may  be  indicated  as  a  tonic 
and  a  tooth-builder;  further  than  this,  medicine  can,  with  our 
present  knowledge,  be  used  only  to  remedy  some  special  abnor- 
mal condition  of  the  system  which  is  believed  to  affect  the  teeth 
injuriously,  as  there  are  no  medicinal  "specifics"  for  dental  caries. 


HYPERSENSITIVE    DENTIN".  1 53 

CHAPTER    XXIX. 

HYPERSENSITIVE  DENTIN. 

Definition. — A  condition  in  which  the  dentin  is  abnormallv  sen- 
sitive. 

Etiology. — The  causes  of  sensitive  dentin  are  both  local  and 
general;  this  can  be  said  with  assurance,  but  we  have  verv  little 
knowledge  of  the  modus  operandi  of  either  class  of  causes.  We 
can  only  say  that  certain  local  conditions  are  associated  with 
hyperesthesia  of  the  dentin.  For  instance,  a  portion  of  dentin  is 
exposed  by  fracture  to  the  fluids  of  the  mouth ;  after  a  day  or  two 
this  exposed  portion  is  excessively  sensitive  to  the  slightest  touch, 
especially  the  contact  of  sweets.  This  is  also  the  case  Avhen  the 
dentin  is  exposed  by  erosion  or  decay,  varying,  in  the  case  of 
decay,  with  the  rapidity  of  the  carious  process  and  the  density  of 
the  tooth-structure. 

It  is  manifest  that  the  softer  and  more  porous  the  tissues 
involved  and  the  greater  the  surface  exposed,  the  more  rapid  and 
intense  •will  be  the  action  of  irritating  agents. 

An  acid  may  be  formed  in  the  mouth  from  decomposable  sub- 
stances, or  the  saljva  and  mucous  secretion  itself  may  be  acid,  due 
to  the  condition  of  the  blood  affected  by  gout  or  rheumatism. 
This  acid  is  a  direct  local  irritant,  which,  with  general  hyperes- 
thesia of  the  nervous  system,  may  cause  excessive  sensitiveness 
of  the  dentin. 

A  general  irritability  of  the  nervous  system,  from  whatever 
cause,  must  necessarily  magnify  the  result  of  any  local  irritant,  and 
therefore  should  be  reckoned  as  a  predisposing  cause  of  sensitive 
dentin. 

The  mechanism  by  which  the  result  of  an  irritant  to  the  dentin 
is  transmuted  into  pain  is  well  explained  by  Dr.  Black  as  fol- 
lows :* 

Fig.  i8  represents  diagrammatically  a  group  of  odontoblasts  with  their 
processes,  the  dentinal  fibrils,  with  a  nerve-branch  in  close  conjuction  with 
the  odontoblasts.     In  case  of  the  irritation  of  the  distal  ends  of  the  processes 


*  "American  System  of  Dentistry,"  vol.  i.  p.  1009.  The  reader  is  also 
referred  to  an  article  by  the  author  in  the  International  Dental  Journal  for 
]\Iarch  1891. 


154 


THE    PRACTICE    OF    DENTAL    MEDICINE. 


of  these  cells  pain  is  produced,  yet  no  nerve  or  nerve-ending  is  touched, 
there  being  no  nerves  in  the  dentin.  Everywhere,  in  the  periphery  of  the 
pulp,  fine  nerve-filaments  may  be  demonstrated  in  close  conjunction  with 
the  odontoblasts,  and  it  seems  evident  that  they  communicate  to  the  sen- 
sorium  the  impression  made  on  the  protoplasm  of  these  cells  through  the 
injury  to  the  fibrils.  .  .  .  The  striped  or  voluntary  muscles  furnish  an 
example  of  the  propagation  of  impulse  along  protoplasmic  bodies  which  is 
like  that  I  have  suggested  in  the  case  of  the  dentinal  fibrils,  except  that  it 
is  an  efferent  instead  of  an  afferent  impulse.  There  is  but  one  motor 
nerve-ending  in  conjunction  with  a  single  muscular  fiber,  no  matter  what 
its  length  (Krause,  Kolliker) ;  this  is  sufficient  to  communicate  the  impulse 
to  contraction  to  the  whole  fiber,  though  it  may  be  much  longer  than  the 
dentinal  fibril.  Here  it  will  be  seen  that  the  passage  of  an  impulse  along  a 
protoplasmic  body  from  a  nerve-ending  seems  demonstrated.  In  the  ex- 
planation offered  of  the  sensitiveness  of  dentin  the  impulse  passes  along  a 
protoplasmic  body  to  a  nerve-ending.  The  conduction  in  the  two  instances 
is  the  same,  but  the  impulse  travels  in  the  opposite  direction. 


V-d 


Group  of  odontoblasts  with  their  processes  (dentinal  fibrils),     a.  Odontoblasts,     b.  Fibrils. 
c.  Nerve-supply.     Irritation  at  the  point  d  produces  pain. 

Treatment. — The  vain  search  which  has  been  made,  and  the 
long  hst  of  remedies  that  have  been  tried,  indicate  the  great  im- 
portance of  this  subject.  In  the  first  place  there  is  no  question  that 
the  manner  of  the  operator  has  an  effect  on  the  patient,  and  this 
may  be  carried  on  to  suggestion,  and  even  hypnotism;  but  at  pres- 
ent the  only  object  is  to  suggest  the  good  influence  of  an  assuring 
manner,  an  earnest  but  quiet  sympathy,  showing  a  desire  to  do  all 
that  may  be  possible  to  prevent  pain  in  any  operation;  a  firm  yet 
light  touch;  and  the  use  of  sharp  instruments. 

The  patient's  confidence  may  be  won  by  operating  upon  the 
easier  and  less  sensitive  cavities  first.  The  manner  of  using  the 
excavator,  as  well  as  its  form,  has  much  to  do  with  lessening  the 
pain;  for  instance,  hatchets  of  either  right  or  obtuse  angle,  of  the 


HYPERSENSITIVE    DENTIN.  155 

smallest  and  most  delicate  pattern,  finely  tempered,  and  sljarp,  will 
enable  the  operator  to  excavate  with  the  least  amount  of  force  or 
friction,  and  therefore  with  the  minimum  amount  of  pain.  It  is 
well  also  to  bear  in  mind  that  in  the  removal  of  tooth-substance, 
the  cutting  should  be,  as  far  as  possible,  in  a  direction  from  the 
pulp  toward  the  periphery  of  the  cavity. 

Warm  air,  or,  indeed,  heat  in  any  form,  is  one  of  the  best 
obtunders  of  sensitive  dentin.  Warm  air  may  be  conveniently 
applied  in  the  following  way :  From  a  tank  of  compressed  air,  or 
a  foot-bellows,  a  stream  of  air  the  temperature  of  which  is  raised 
to  125°  F.,*  is  directed  into  the  cavity  and  maintained  for  a  minute 
or  two. 

In  many  sensitive  teeth,  pain  follows  the  first  application  of  the 
air,  and  in  order  to  avoid  this  it  is  necessary  to  raise  the  tempera- 
ture of  the  tooth  very  gradually,  which  may  be  done  by  regulating 
the  distance  of  the  delivery  tube  from  the  tooth.  If  a  finger  is 
placed  on  the  tooth  to  which  the  air  is  applied,  it  will  be  found 
that  the  whole  tooth  gets  warm,  which  may  serve  as  a  guide  in 
regulating  the  amount  of  heat.  It  will  be  found  also  that  the 
tooth  cools  in  a  very  short  time,  and  sensitiveness  returns,  but  the 
air  may  be  applied  by  an  assistant  while  the  excavating  is  going 

on.t 

Formerly  the  writer  used  a  thermometer  within  the  nozzle  of 
the  glass  tube  conveying  the  air,  but  after  a  considerable  use  of  it 
he  was  enabled  to  judge  very  well  by  applying  the  finger  to  the 
tooth  and  noting  the  heat. 

Of  the  innumerable  remedies  to  be  applied  to  the  cavity,  only 
a  few  will  be  mentioned.  Carbolic  acid  in  full  strength  sometimes 
has  a  good  effect  when  applied  to  the  cavity,  but  it  is  not  readily 
absorbed,  and  cannot  therefore  be  made  effective  to  any  satisfac- 
tory extent.  Zinc  chlorid  is  certainly  an  effective  agent  and  has 
been  in  use  for  a  long  time.  Its  proper  application  is  thus  de- 
scribed by  Dr.  Jack: 

To  secure  the  proper  action  of  chlorid  of  zinc,  it  is  essential  perfectly 
to  protect  the  cavity  from  the  ingress  of  water,  whether  by  the  inflowing  of 
saliva  or  by  the  insensible  entrance  of  any  fluids  by  capillary  approach.     It 


*  It  is  necessary  that  the  heat  be  applied  within  twelve  inches  of  the 
delivery  tube,  as  the  air  soon  cools  in  being  conveyed  from  the  source  of 
heat.     The  heat  may  be  generated  either  by  means  of  gas  or  electricity. 

t  In  his  experiments  with  warm  air,  the  author  is  much  indebted  to 
Prof.  E.  T.  Darby,  of  Philadelphia. 


156  THE    PRACTICE    OF    DENTAL   MEDICINE. 

is  also  important  to  exclude  the  vapors  of  the  mouth.  To  make  sure  of  the 
exclusion  of  all  moisture  it  is  necessary  to  envelop  the  tooth — and  fre- 
quently, also,  its  neighbors^ — with  rubber-dam,  securing  it  with  a  thread  at 
the  gum.  If  the  cavity  be  a  simple  one,  it  should  have  placed  in  it,  after 
being  dried,  a  pledget  of  cotton  filled  with  the  saturated  deliquescent  solu- 
tion of  the  chemical.  It  is  necessary  that  the  agent  should  be  chemically 
pure  and  liquefied,  and  to  secure  full  saturation  it  is  important  to  observe 
that  the  vessel  should  always  contain  some  of  the  undissolved  crystals. 

The  remedy  generally  causes  pain  at  first,  and  in  some  cases  this  pain 
is  extreme.  This  can  be  modified  by  air-drying  the  cavity  and  applying 
for  a  moment  carbolic  acid,  the  carbolization  of  the  cavity  appearing  not  to 
interfere  with  the  action  of  the  chlorid. 

In  deep  cases  the  part  of  the  cavity  nearest  the  pulp  should  in  the 
beginning  be  perfectly  protected  from  the  action  of  the  agent,  and,  as  the 
sensibility  of  the  dentin  is  considerable  only  at  the  periphery,  the  usual  ob- 
jection to  the  remedy  is  removable. 

The  remedy  should  be  permitted  to  remain  until  all  the  pain  it  causes 
has  passed  away.  It  will  be  frequently  observed  that  the  pain  diminishes 
very  much  after  a  little  while,  and  then  recurs.  It  is  not  until  the  secondary 
pain  has  subsided  that  the  excavation  should  be  performed. 

There  are  several  reasons  why  chlorid  of  zinc  has  not  had  the  general 
repute  to  which  its  properties  entitle  it.  It  has  by  many  practitioners  been 
regarded  as  a  very  painful  and  uncertain  remedy.  This  has  not  agreed  with 
the  writer's  experience,  who  has  made  it  his  chief  reliance  in  severe  cases 
for  many  years,  and  he  regards  it  as  the  only  certain  and  reliable  escharotic 
for  this  purpose  when  warmed  air  and  carbolic  acid  prove  inefficient.  The 
uncertain  results  from  its  usejnay  have  arisen  from  disregard  of  the  means 
necessary  to  secure  its  efficiency,  combined  with  an  indisposition  to  tolerate 
the  delay  which  attends  its  use.  This  delay,  however,  is  more  apparent  than 
real,  as  what  time  is  lost  in  futile  attempts  to  manipulate  very  sensitive 
cavities,  in  misdirected  and  inefficient  efforts,  is  more  than  compensated 
for  by  the  freedom  and  rapidity  with  which  the  case  may  be  proceeded  with 
after  the  treatment  is  over.  An  excellent  method  to  obviate  the  loss  of 
time  is  to  apply  the  rubber-dam,  make  the  application  as  above  described, 
pass  a  ligature  around  the  free  portion  of  the  rubber,  at  a  short  distance 
from  the  tooth,  so  tightly  that  water  cannot  enter,  and  then  cut  off  the 
extruding  portion  of  the  rubber.  Operations  can  then  be  carried  on  in 
connection  with  some  other  tooth  in  another  part  of  the  mouth  until  the 
sensibility  is  believed  to  be  subdued.  The  cavity,  after  being  thoroughly 
washed  and  permitted  to  remain  open  for  a  short  time  to  allow  the  excess 
of  zinc  chlorid  that  has  not  combined  to  be  dissolved  away,  may  be  filled 
temporarily  if  impracticable  to  complete  the  operation  at  that  sitting.  The 
postponement  of  such  cases  when  treated  in  this  way  is  frequently  advan- 
tageous. Sensibility  treated  in  this  manner,  when  the  remedy  under  consid- 
eration is  indicated,  is  usually  followed  by  the  most  satisfactory  results. 

There  remain  to  be  considered  the  general  principles  guiding  the  selec- 
tion of  this  remedy.  Although,  when  its  administration  is  continued  for  no 
longer  time  than  is  required  to  subdue  dentinal  sensibility,  it  cannot  pene- 


HYPERSENSITIVE    DENTIN.  157 

trate  deeply  the  tubular  structure  because  its  combination  with  the  albumin 
limits  the  depth  of  its  action,  still  it  has  energetic  properties  and  is  inad- 
missible under  several  conditions. 

As  it  can  do  harm  only  by  an  extension  of  action  upon  the  organic 
elements  of  the  dentin,  it  will  at  once  be  observed  that  in  all  cases  its  dan- 
ger is  in  proportion  to  the  softness  of  the  structures  and  the  near  proximity 
of  the  dental  pulp.  It  is  therefore  manifest  that  in  teeth  of  hard  structure 
not  near  the  pulp,  danger  would  be  less  marked  than  in  softer  teeth  at  the 
same  distance  from  that  organ.  In  the  harder  teeth,  also,  where  usually 
the  caries  is  less  rapid  and  the  consolidation  over  the  pulp  more  nearly 
complete,  the  safety  must  be  greater  than  where  the  opposite  conditions 
exist.  In  all  cases,  however,  the  extreme  sensibility  is  always  found  at  the 
peripheral  limits  of  the  tubules,  and  as  before  pointed  out,  it  is  not  at  all 
difficult  to  limit  the  action  of  the  zinc  to  that  part  alone;  and  in  practical 
experience  it  is  found  necessary  to  protect  the  central  parts  of  the  cavity, 
only  in  teeth  of  soft  character  and  in  the  incomplete  teeth  of  young  subjects. 

The  following  prescription  containing  veratria  has  been  recom- 
mended by  Dr.  Bogue  of  New  York: 

IJ — Veratrinae,  gr.  iv; 

Acidi  tannici,  gr.  j ; 

Alcoholis,  gtt.  XX ; 

Glycerini,  oj ; 

Acidi  carbolici,  oij.         M. 

In  applying  this  remedy,  dryness  of  the  tooth  should  be  main- 
tained, the  drug  applied,  and  allowed  to  remain  for  a  time,  while 
attention  is  given  to  some  other  tooth.  After  removing  the 
remedy  the  cavity  should  be  cleansed  with  alcohol  and  dried 
with  warm  air. 

The  "Robinson  remedy"  consists  of  equal  parts  of  carbolic  acid 
and  caustic  potash  triturated  in  a  mortar  until  a  paste  is  formed. 
This  agent  is  certainly  entitled  to  a  place  in  the  list  of  reliable 
remedies.  Cocain  is  largely  used  as  a  local  anesthetic  and  has  been 
known  as  such  for  nearly  fifteen  3-ears;  it  is  a  valuable  remedy 
when  its  absorption  can  be  secured.  In  some  cases,  if  the  cavity 
be  thoroughly  dried,  a  solution  of  cocain  placed  within  it  will  be 
absorbed  sufficiently  to  obtund  in  a  moderate  degree.  It  is  my 
opinion  that  if  the  solution  be  made  in  chloroform  or  ether,  it  will 
be  absorbed  more  readily  than  will  the  aqueous  solution, 

A  solution  of  cocain  on  cotton  has  been  placed  in  the  nostrils 
for  its  obtunding  effect  on  the  incisor  teeth,  and  some  have 
reported  good  results  from  this  method.  The  author  failed  to  get 
sufficiently  good  results  to  make  this  a  rule  of  practice,  and  he 
would  add  a  word  of  caution  to  those  trvins;  this  method, — that  in 


158  THE    PRACTICE    OF    DENTAL   MEDICINE. 

placing  the  cotton  an  excess  of  the  solution  may  run  back  to  the 
throat,  producing  disagreeable  and  possibly  dangerous  symptoms. 

Recently,  the  absorption  of  cocain  and  other  remedies  in  solu- 
tion has  been  accomplished  by  means  of  cataphoresis.  Much 
care  is  necessary  in  conducting  the  cataphoresis  generally,  and 
especially  in  applying  the  electric  current,  as  pain  may  be  caused 
thereby.  The  time  consumed  in  the  application  of  this  method 
has  caused  some  to  abandon  it  entirely,  as  the  exceptional 
cases  may  be  treated  as  effectually  and  more  quickly  by  other 
means,  such  as  the  inhalation  of  ether.  The  application  of  cocain 
alone  or  with  guaiacol,  by  cataphoresis,  is  not  a  new  method  in 
point  of  origin,  yet  it  has  only  recently  come  into  prominence  and 
been  reduced  to  practical  use  for  the  profession  at  large.  By  this 
method  the  medicinal  agent  is  supposed  to  be  driven  into  the  sub- 
stance of  the  tissue  to  which  it  is  applied,  and  thus  made  effectual. 
As  solutions  applied  to  the  dentin  in  the  ordinary  way  are  absorbed 
with  difficulty,  if  at  all,  the  value  of  this  process  must  be  apparent. 
In  order  to  produce  cataphoresis,  it  is  necessary  to  have  a  steady 
current  of  galvanic  electricity  conveyed  by  electrodes;  the  negative 
is  similar  to  the  sponge  electrodes  of  any  battery,  with  the  excep- 
tion that  it  should  be  interchangeable,  so  that  it  may  be  taken  out 
and  another  put  in  its  place  for  the  next  patient.  Spunk  may  be 
more  readily  used  for  this  purpose  on  account  of  its  being  adapted 
to  th-i  holder;  blotting  paper  or  lintine  may  also  be  used. 

The  positive  electrode  should  be  of  platinum,  of  such  shape  as 
to  be  introduced  into  cavities  of  the  teeth.  The  electric  current 
should  be  steady,  and  for  this  purpose  the  dry  chlorid  of  silver 
cell  is  best.  Another  essential  is  the  beginning  with  a  small 
amount  of  current  and  increasing  gradually,  which,  for  example, 
may  be  accomplished  by  the  Wheeler  fractional  volt  selector,  or 
Willms  current-controller  attached  to  the  battery.*  Also,  a  mil- 
liamperemeter  for  measuring  the  current  is,  though  not  essential, 
extremely  useful.  In  the  majority  of  cases  ten  volts  will  be  suffi- 
cient, although  fifteen  to  twenty  volts  are  often  used.  The  usual 
steps  in  the  application  of  this  method  are  as  follows:  The  elec- 
trode containing  the  sponge  (negative)  is  held  either  in  the  hand 
or  against  the  cheek;  or,  as  Dr.  Jack  suggests,  it  may  be  inserted 
through  an  Opening  in  the  band  which  supports  the  rubber-dam, 
and  thus  held.     It  should  first  be  thoroughly  moistened,  and  the 

*  Various  current  controllers  are  now  in  the  market. 


HYPERSENSITIVE    DENTIN.  I59 

writer  advises  also  the  application  of  a  very  little  salt.  With  the 
rubber-dam  in  position,  the  precaution  is  taken  to  insulate  adjoin- 
ing metal  fillings  by  coating  with  wax,  gutta-percha,  or  varnish. 

A  pledget  of  cotton  is  now  saturated  with  a  twenty  per  cent, 
solution  of  cocain  and  placed  in  the  cavity.  The  positive  electrode 
of  platinum,  of  a  suitable  shape,  is  placed  in  firm  contact  with  the 
cotton  and  either  held  by  the  operator  or  affixed  to  the  end  of  a 
flexible  wire,  which  is  soldered  to  a  clamp  over  a  tooth;  this  may 
be  bent  so  as  to  press  against  the  cotton  in  the  cavity. 

The  electrodes  being  thus  placed,  the  current  is  let  on  in  the 
smallest  possible  degree,  and  increased  as  the  patient  is  able  to 
bear  it.  As  sensation  is  lessened,  the  current  may  be  increased 
more  rapidly,  until,  when  considerable  current  is  turned  on  and  no 
irritation  results,  the  indication  is  that  sensitiveness  is  controlled 
sufficiently  for  the  excavation  of  the  dentin.  The  time  usually 
needed  for  the  accomplishment  of  this  end  varies  between  seven 
and  twenty-five  minutes. 

Sulfuric  ether,  ethyl  chlorid,  and  similar  agents  have  been  used 
successfully  as  a  spray  for  the  painless  excavation  of  superficial 
cavities.  These  agents  are  certainly  effective,  take  but  little  time 
for  their  application,  and  if  used  with  due  caution  may  not  cause 
injurious  results  from  the  intense  cold  which  is  produced;  but  there 
are  other  and  safer  means  for  obtunding  sensitive  dentin. 

The  sensitive  cavity  may  be  made  dry,  medicated,  and  filled 
with  a  temporary  stopping  for  a  few  days,  or  weeks,  as  the  case 
may  be,  with  benefit  to  the  sensitive  condition;  also  a  paste  of 
bicarbonate  of  sodium  may  be  inserted  into  the  dry  cavity  from 
time  to  time  while  operating. 

Constitutional  Treatment  of  Hypersensitive  Dentin. — "Rapid 
breathing,"  as  demonstrated  by  Dr.  G.  A.  Bonwill,  is  effectual  in 
some  cases,  and  should  be  kept  in  mind,  so  that  it  may  be  em- 
ployed when  the  case  to  which  it  is  best  adapted  presents  itself. 

One  of  the  most  reliable  and  effective  agents  to  be  employed 
in  hypersensitive  dentin  is  sulfuric  ether  by  inhalation.  It  is 
sometimes  the  case  that  half  a  dozen  inhalations  will  suffice,  but,  in 
all  cases,  the  operator  may  excavate  very  soon  after  the  first  effects 
of  the  ether  are  manifested.  The  patient  is  not  unconscious,  yet 
there  is  entire  freedom  from  the  pain  of  excavating;  nor  is  suffi- 
cient ether  given  to  produce  nausea,  or  other  unpleasant  after- 
effects. 


l6o  THE    PRACTICE    OF    DENTAL    MEDICINE. 

Nitrous  oxid  gas,  with  various  proportions  of  oxygen,  has 
given  good  results,  but  it  does  not  in  all  cases  render  the  operation 
painless,  unless  the  patient  is  carried  nearly  or  quite  to  the  point  of 
unconsciousness;  if  this  occurs,  the  dentist  loses  the  co-operation 
of  the  patient  in  facilitating  the  work,  while  there  is  often  the 
rigidity  of  muscles  characteristic  of  this  agent,  which  is  a  decided 
hindrance. 

Although,  in  many  cases,  chloroform,  like  nitrous  oxid,  has 
given  most  satisfactory  results,  it  is  open  to  the  same  criticism. 
This  is  to  be  regretted,  as  there  can  be  no  objection  to  the  odor, 
as  in  the  use  of  ether.  In  thus  administering  chloroform,  the  pre- 
caution should  be  taken  to  tip  the  operating  chair  well  back;  to 
administer  a  stimulant,  and  to  cause  the  patient  to  inhale  oxygen 
with  the  chloroform.  • 

During  the  time  from  1880  to  1883,  frequent  use  was  made  of 
the  inhalation  of  ethyl  bromid  for  sensitive  dentin,  but  it  was  found 
to  be  an  unstable  fluid,  and  it  has  no  special  advantages  over  chlo- 
roform. 

In  general  irritability  of  the  nervous  system,  sodium  bromid 
may  be  administered  with  benefit.  To  secure  the  best  results  it 
should  be  taken  during  the  day  previous  to  the  operation,  in  ten- 
grain  doses,  every  three  hours,  and  a  dose  of  twenty  grains  half 
an  hour  before  the  operation.  This  remedy  should  be  well  diluted 
with  water,  at  least  half  a  glass  for  each  dos^.  In  other  cases  it 
may  be  necessary  that  the  patient  should  receive  treatment  for 
weeks,  either  by  the  dentist  or  the  physician,  in  order  not  only  that 
the  dentin  may  thereby  be  rendered  less  sensitive,  but  that  the 
patient  may  be  better  able  to  bear  the  operation. 

In  making  appointments  for  such  patients,  morning  hours  are 
usually  preferable.  Notwithstanding  this,  a  time  should  be  selected 
when  the  patient  is  in  his  best  physical  condition.  Patients  them- 
selves ought  to  know  that  during  or  immediately  preceding  or  fol- 
lowing the  menstrual  period  is  not  the  best  time  for  undergoing 
dental  operations. 

Prof.  Thomas  Fillebrown,  of  Boston,  has  kindly  furnished  the 
following  description  of  his  method  of  employing  "suggestion"  as 
a  remedy  in  operating  on  hypersensitive  dentin: 

Suggestion  has  now  become  one  of  the  well-acknowledged  remedies 
for  sensitive  dentin,  and  I  learn  from  reports  and  conferences  with  my  fel- 
low practitioners  that  it  is  becoming  more  common  every  day.     For  years  I 


HYPEREMIA  OF  THE  DENTAL  PULP.  l6l 

have  used  it  constantly  and  have  found  it  efficient  in  more  than  three- 
fourths  of  my  cases.  At  first  I  thought  it  necessary  to  induce  hypnosis  be- 
fore using  the  suggestion,  but  a  little  later  I  found  the  formal  hypnosis 
entirely  unnecessary,  and  that  relaxation  and  deep  breathing  induced  the 
same  receptive  state  as  before  obtained,  hence  the  use  of  suggestion  has 
become  very  simple  and  easy,  and  within  the  reach  of  every  one  interested 
to  try  it.     The  process  is  as  follows: 

1st.  The  operator  shall  induce  a  feeling  of  relaxation  and  repose  in 
himself. 

2d.  By  request  and  example,  induce  in  the  patient  a  complete  relaxa- 
tion of  all  the  muscles  of  the  body,  including  those  of  the  face  and  jaws. 

3d.  By  request  and  example  induce  deep,  full,  steady  breathing  by  the 
patient. 

4th.  Make  a  statement  that  this  will  obtund  the  pain  and  lessen  the  fear, 
and  prevent  shock  from  the  operation.  One  or  two  minutes  will  prepare 
the  patient. 

5th.  Use  a  sharp  instrument  lightly  and  skillful^,  avoiding  any  sudden 
plunge  or  cut.  If  a  spot  is  found  to  be  sensitive,  wait  a  moment,  repeat  the 
suggestion,  and  the  remedial  efifect  will  be  renewed. 

The  previous  suggestion  of  the  absence  of  shock  will  prevent  the  oc- 
casional hurt  from  arousing  any  condition  of  dread  of  the  next  cut.  Laving 
the  hands  upon  the  head  and  exerting  a  little  pressure  upon  the  middle  of 
the  forehead  between  the  eyebrows  will,  I  think,  be  found  a  decided  aid  in 
the  process.  A  little  practice  will  enable  any  one  of  ordinary  intelligence 
and  tact  to  practice  this  method  successfully. 

It  will  also  be  found  a  powerful  adjunct  in  connection  with  any  other 
agents  that  maj^  be  used  for  this  purpose,  some  of  which  should  be  at  the 
immediate  command  of  every  operator. 


CHAPTER    XXX. 
HYPEREMIA  OF  THE  DENTAL  PULP. 

Definition.— Hyperemia  of  the  dental  pulp  may  be  defined  as  a 
condition  in  which  there  is  an  excessive  amount  of  blood  within 
the  vessels  of  this  tissue. 

Etiology. — Hyperemia  of  the  pulp  may  occur  as  the  result  of 
a  deep-seated  cavity  of  a  tooth  the  pulp  of  which  is  not  necessarily 
exposed  thereby.  The  cavity  may,  or  may  not,  have  a  filling;  but 
if  it  does  contain  a  filling,  the  character  of  the  filling  material  will 
have  an  influence  in  producing  hyperemia. 


l62  THE    PRACTICE    OF    DENTAL    MEDICINE. 

Sudden  changes  of  heat  and  cold  may  not  only  act  as  causes 
of  hyperemia,  but  a  hyperemic  pulp  is  extremely  sensitive  to  ther- 
mal changes. 

Pathology. — From  our  definition  of  hyperemia  we  know  that 
there  is,  in  this  condition,  an  excess  of  blood  in  the  vessels  of  the 
part  affected.  The  vessels  are  distended,  but  they  may  return  to 
their  normal  caliber  and  present  no  sign  of  physiological  disturb- 
ance. This  can  hardly  be  called  a  pathological  process;  but  this 
process  may  be  repeated  until  the  vessels  lose  their  elasticity  and 
become  permanently  enlarged,  which  is  a  pathological  condition. 
By  reason  of  this  abnormal  state,  the  affected  tissue  is  thereby 
rendered  more  susceptible  to  future  inflammatory  attacks — if, 
indeed,  inflammation  does  not  immediately  follow  the  hyperemic 
state.  The  degree  to  which  the  bloodvessels  may  be  stretched 
varies  greatly;  in  some  cases  they  become  enlarged  to  an  enormous 
extent. 

Dr.  Black  says  that  the  vessels  are  distended  to  a  greater  extent 
in  the  coronal  portion  of  the  pulp,  but  that  there  is  no  symmetry 
in  the  enlargement,  as  this  condition  prevails  in  a  very  irregular 
way  throughout  the  pulp-tissue. 

The  following  from  Dr.  Black,  in  the  "American  System  of 
Dentistry,"  is  instructive: 

Fig.  19  represents  a  field  from  the  margin  of  a  section  of  the  pulp  of  a 
tooth  extracted  during  a  severe  paroxysm  of  pain,  the  vessels  containing  the 
natural  injection  except  at  some  points.  This  was  a  case  of  extreme  sensi- 
tiveness to  thermal  changes,  in  which  severe  paroxysms  of  pain,  lasting  for 
an  hour  or  more,  were  occasionally  occurring,  seemingly  excited  by  very 
trivial  changes  of  temperature.  This  condition  had  continued  for  several 
weeks.  The  tooth  was  inuch  decayed,  but  the  pulp  was  not  actually  ex- 
posed. The  examination  reveals  no  signs  of  inflammatory  changes  what- 
ever. This  I  find  common  in  those  cases  in  which  a  pulp  has  become  ab- 
normally sensitive  to  thermal  changes  without  exposure  or  irritation  from 
external  sources  other  than  changes  of  temperature.  This  forms  an  im- 
portant feature  of  the  pathology  of  the  dental  pulp,  for  the  reason  that  its 
causes  are  so  constantly  present  and  their  action  augmented  in  every  case 
of  filling  with  metal.  It  is  liable  to  occur  in  the  pulp  of  any  tooth,  however 
sound  or  otherwise  healthy. 

Sensitiveness  to  thermal  changes  in  a  certain  degree  is,  as  has 
been  explained  above,  the  normal  sensory  function  of  the  pulp.  In 
each  instance  of  the  exercise  of  this  function  there  is  an  unusual 
amount  of  blood  sent  to  the  organ.  This,  when  in  a  reasonable 
degree,  is  healthful, — a  temporary  physiological  hyperemia  which 


HYPEREMIA  OF  THE  DENTAL  PULP. 


163 


calls  out  a  simple  warning  in  the  form  of  an  unpleasant  sensation, 
and  immediately  passes  away.  It  is  evident  in  this  case  that  no 
injury  results,  but  when  this  is  repeated  frequently  with  a  degree 
of  thermal  change  that  is  inordinate,  the  vessels  finally  fail  to  con- 
tract and  remain  overfilled  with  blood,  at  the  same  time  acquiring 
an  unusual  degree  of  susceptibility  to  thermal  influences  so  that 
very  slight  changes  produce  pain. 


Hyperemia  of  the  dental  pulp  :  showing  the  natural  injection  of  the  vessels,  a  a.  Membra  na 
«boris,  or  layer  of  odontoblasts,  b  b  b  b.  Vessels  distended  with  blood,  c  c  c  c.  Points  from 
which  the  blood  has  fallen  in  handling  the  section. 

There  is  now  a  question  of  how  much  this  fullness  of  the  vessels 
is  due  to  the  mechanical  stretching  which  the  pressure  of  the  blood 
has  exerted,  and  how  much  is  due  to  nervous  control  through  the 
vasomotor  system.  The  fact  that  the  vasomotor  system  of  nerves 
controls  the  caliber  of  the  bloodvessels  to  a  certain  extent  is  well 
known,  but  it  seems  reasonable  to  suppose  that  the  permanent  en- 
largement is  due  in  some  degree  to  stretching  and  loss  of  elasticity 
of  the  vessel  walls. 

The  distension  may  also  be  due  in  part  to  a  partial  paralysis  of 


164 


THE    PRACTICE    OF    DENTAL    MEDICINE. 


the  vasomotor  nerves  which  supply  the  parts  affected,  in  which 
case,  if  in  the  early  stages,  recovery,  partial  or  complete,  may  take 
place.  The  degree  of  distension  is  well  shown  in  Fig.  20,  from 
Black,  who  remarks  that  the  distension  is  only  shown  when  the 
tooth  has  been  extracted  during  a  paroxysm  of  pain,  while  in  sec- 
tions prepared  from  pulps  of  teeth  which  were  extracted  during  an 
interval  of  quiet,  nothing  unusual  is  shown.  The  distension,  as 
will  be  noticed,  is  enormous  at  certain  points,  being  in  some  places 
increased  to  several  times  the  normal  caliber.  When  this  process 
is  carried  further,  and  there  is  migration  of  the  blood-corpuscles, 
the  inflammatory  process  has  begun,  hyperemia  being  a  process 
which,  if  continued,  leads  to  inflammation. 

Fig.  20. 


Dilated  bloodvessels  from  the  dental  pulp  in  hyperemia  :  from  tooth  extracted  during  a 
paroxysm  of  intense  pain. 


Symptoms. — These  sudden  changes  in  temperature  occasion 
paroxysms  of  pain  of  an  unusually  violent  character,  with  intervals 
of  quiet  which  grow  less  and  less  as  the  case  approaches  inflam- 
mation. Extreme  sensitiveness  to  heat  and  cold,  and  especially 
heat,  is  a  marked  and  early  symptom,  manifest  by  pain  as  above 
described.  The  pain  is  not  always  easily  located  in  the  tooth 
affected,  but  is  usually  referred  to  some  of  the  approximate  teeth, 
though  at  times  there  is  a  pain  in  the  ear,  and  more  rarely  in  the 
face,  extending  to  the  eye. 

Course,  Duration,  etc. — Hyperemia  may  exist  for  only  a  week 
after  a  metal  filling  has  been  introduced,  and  cease  without  treat- 
ment, or  it  may  continue  for  several  months.  The  writer  has  ob- 
served a  case  lasting  four  months,  the  trouble  ceasing  without 


ACUTE    PULPITIS.  165 

special  treatment  and  remaining  absent  up  to  the  present  time, 
about  twenty  years. 

Prognosis. — The  prognosis  is  often  favorable,  but  on  the  whole 
uncertain,  depending  upon  the  degree  of  irritation  to  the  pulp,  the 
general  state  of  the  patient,  and  the  length  of  time  the  condition 
has  existed. 

Diagnosis. — For  the  purpose  of  forming  a  diagnosis,  attention 
is  directed  to  the  pain,  which  is  usually  due  to  thermal  changes;  the 
period  of  rest  occurring  between  the  times  of  thermal  irritation; 
the  absence  of  tenderness  of  the  tooth  to  percussion;  the  parox- 
ysmal character  of  the  pain,  and  the  history  of  the  case. 

Treatment. — Instruct  the  patient  to  shield  the  affected  tooth  or 
teeth  from  heat  or  cold,  not  only  to  avoid  the  pain  which  they  pro- 
duce, but  to  give  the  parts  an  opportunity  to  recuperate.  See  that 
there  is  sufhcient  non-conducting  material  covering  the  pulp. 
Perhaps  a  change  may  be  necessary  in  the  filling  material;  for 
instance,  from  cement  to  gutta-percha.  It  may  be  necessary  to 
place  a  gutta-percha  cap  over  the  entire  tooth  to  shield  it  more 
perfectly  from  thermal  changes.  A  capsicum  plaster  may  often  be 
placed  on  the  gum  with  benefit.  Attention  to  the  lower  digestive 
tract  is  important,  and  a  laxative  or  even  a  cathartic  may  be  bene- 
ficial. 


CHAPTER    XXXI. 

PULPITIS— ACUTE;  CHRONIC. 
ACUTE    PULPITIS. 

Etiology. — The  fact  that  the  dental  pulp  is  peculiarly  susceptible 
to  thermal  changes,  and  thereby  often  the  subject  of  hyperemia, 
makes  it  easy  to  see  how  this  condition,  when  the  cause  is  not 
removed,  may  gradually  pass  into  an  inflammatory  state. 

When  caries  approaches  the  pulp  so  that  food  and  other  sub- 
stances irritate  it,  pulpitis  results.  It  is  often  the  case  that  the  pulp 
is  slightly  exposed  before  any  irritation  of  it  occurs.  Erosion, 
abrasion,  fracture,  the  application  of  extremes  of  heat  or  cold  for 
obtunding  hypersensitive  dentin,  etc.,  all  act  as   causes.     Caries 


l66  THE    PRACTICE   OF    DENTAL   MEDICINE. 

is  the  most  common  cause,  but  it  rarely  produces  inflammation  of 
the  pulp  until  that  is  exposed. 

Pathology. — An  interesting  feature  of  the  pathology  of  inflam- 
mation of  the  dental  pulp  is  that  the  inflammatory  process  may 
occupy  only  a  small  portion  of  the  pulp  tissue.  Dr.  Black  says 
that  this  is  very  common;  that  cases  in  which  the  inflammation  is 
diffused  through  the  entire  portion  of  the  pulp  are  the  exception 
and  not  the  rule,  and  that  when  the  pulp  is  totally  destroyed  by 
the  inflammatory  process  it  is  done  gradually,  beginning  at  a  cer- 
tain point  and  extending  little  by  little  throughout  its  entire  extent 
by  the  process  of  suppuration. 

The  following  illustrations  after  Black  show  the  various  tissue 
changes  in  inflammation  of  the  pulp.  Fig.  21  shows  a  section  of 
the  inflamed  pulp  with  normal  tissue  cells  at  a,  and  at  c  may  be 
seen  the  migrated  white  blood-cell  under  the  process  of  develop- 
ment and  self-division.  These  normal  cells  disappear  as  the  in- 
flammation goes  on,  and  other  cells  belonging  to  the  white  blood- 
cell  type  make  their  appearance;  this  is  well  shown  in  Fig.  22. 

Symptoms. — Inflammation  of  the  dental  pulp  presents  the  same 
general  characteristics  that  may  be  seen  in  any  other  inflamed 
tissue.  The  well-known  cardinal  symptoms  are  present,  although 
modified  by  environment,  so  that  the  redness  may  be  seen  after 
extraction  only,  and  the  swelling  is  limited  by  the  bony  walls  of 
the  pulp-cavity. 

We  have  hyperemia  still  present,  and  we  have  severe  pain  in 
hyperemia,  but,  as  new  features  are  developed,  the  character  of 
the  pain  is  changed  from  the  paroxysmal  and  spasmodic,  with 
periods  of  rest,  to  a  steadier  pain  which  is  inclined  more  and  more 
to  be  continuous.  As  the  inflammation  progresses,  the  pain  is 
more  likely  to  be  brought  on  by  lying  down,  and  the  patient  there- 
fore gives  a  history  of  pain  during  the  night. 

In  fully  established  inflammation  of  the  pulp  an  actual  exposure 
is  nearly  always  found;  also  in  a  number  of  cases  inflammation 
and  destruction  of  the  pulp  have  occurred  with  no  symptoms  what- 
ever. 

The  pain  which  is  located  in  the  affected  tooth  may  continue 
for  hours  at  a  time,  with  periods  of  abatement,  according  to  the 
stage  of  the  inflammatory  process.  The  affected  tooth  is  not  sensi- 
tive to  percussion,  nor  is  it  protruded,  and  there  is  no  swelling  of 
the  gum. 


ACUTE    PULPITIS. 


167 


Diagnosis.- — The  diagnosis  is  based  on  the  fact  that  the  pain  is 
more  nearly  continuous  than  in  hyperemia,  and  increases  on  lying 
down;  also  upon  a  history  of  decay  and  exposure  with  previous 
symptoms  of  hyperemia.  The  tooth  may  or  may  not  have  been 
filled.  There  is  sensitiveness  to  heat  and  cold  as  in  hyperemia, 
and  in  neither  condition  is  there  any  tenderness  on  percussion. 

Fig.  21. 


..^^ .  .. 


n   [Inflammation  of  dental  pulp,    a  a.  Normal  cells,    bbbb.  Inflammatory  elements,  ''c.  Cells 
in  process  of  division.     (j>,;  in.) 

Fig.  22. 


Section  of  dental  pulp  :  showing  the  invasion  of  the  inflammatory  process  along  the  course 
of  the  veins — the  diapedesis  of  the  white  blood-corpuscles. 

Treatment. — The  inflamed  pulp  is  the  seat  of  severe  pain.  Ob- 
viously, the  first  thing  to  do  is  to  quiet  this  pain;  and  indeed,  all 
subsequent  treatment  with  the  view  of  cure  and  preservation  of 
the  pulp  depends  upon  our  abilit}^  to  relieve  the  pain. 

This  we  may  try  to  do  in  various  ways,  according  to  the  condi- 
tion which  causes  the  trouble.     If  there  is  a  filling  which  presses 


l68  THE    PRACTICE    OF    DENTAL   MEDICINE. 

unduly  upon  the  pulp,  or  if  the  condition  be  due  to  the  size  of  the 
filling,  and  the  pulp  has  been  repeatedly  irritated,  thus  inducing 
inflammation,  the  filling  must  be  removed.  If,  after  the  filling  has 
been  removed,  it  is  impossible  to  subdue  the  pain,  it  then  becomes 
a  question  whether  the  pulp  may  be  preserved  alive,  and  this  will 
depend  in  large  measure  upon  the  length  of  time  the  patient  has 
been  suffering.  In  the  writer's  experience,  if  there  is  an  actual 
exposure  with  a  history  of  three  to  five  days  in  which  there  has 
been  severe  pain  nearly  all  the  time  (a  pain  may  be  said  to  be 
severe  when  it  is  sufficient  to  render  the  night  a  sleepless  one), 
there  is  little  hope  of  maintaining  a  permanent  comfortable  condi- 
tion with  the  pulp  alive. 

While  many  cases  of  this  kind  may  be  carefully  capped  and  the 
pulp  preserved  alive  for  two  and  perhaps  three  years,  sooner  or 
later  the  majority  will  present  with  a  dying  or  dead  pulp  for  treat- 
ment. After  the  removal  of  the  filling  or  if  there  is  an  open  cavity, 
a  selection  may  be  made  from  the  many  local  obtundents;  for 
instance,  if  the  case  be  one  of  beginning  acute  inflammation  of  the 
pulp,  one  which  has  just  passed  the  border  line  of  hyperemia,  car- 
bolic acid  or  oil  of  cloves  is  applicable;  if  however,  the  case  be 
advanced  in  inflammation,  chloroform  or  tincture  of  aconite-root 
would  be  best  suited  to  the  condition. 

If  there  is  general  fever  and  excitement  and  the  local  measures 
fail,  the  following  internal  treatment  may  be  found  of  advantage : 

IJ — -Tinct.    aconit.    rad.,  gtt.  vj ; 

Tinct.  opii  deod.,  oij; 

Aquse,  ovj.         M. 

Sig. — A  teaspoonful  in  water  every  half-hour  till  three  doses  have  been 
taken  or  until  the  pain  is  relieved. 

As  tinctures  of  aconite-root  vary  greatly  in  strength,  it  is  always 
best  to  have  an  understanding  with  the  druggist  as  to  the  strength 
of  the  tincture  which  is  to  be  used,  and  modify  the  dose  accord- 
ingly. 

It  is  absolutely  necessary  that  free  movements  of  the  bowels  be 
maintained  throughout  the  treatment. 

After  the  pain  is  under  control,  the  pulp  may  then,  and  only 
then,  be  devitalized,  if  this  is  deemed  necessary.  It  may,  however, 
be  advisable  to  remove  the  pulp  immediately  by  the  application, 
either  cataphorically  or  by  injection,  of  cocain,  or  by  means  of 
general  anesthesia. 

The  question  of  capping,  and  preserving  the  pulp  alive,  depends 


CHRONIC    PULPITIS. 


169 


upon  the  length  of  time  the  pain  has  continued  and  the  readiness 
with  which  it  may  be  controHed, 


CHRONIC    PULPITIS. 


The  varying  conditions  under  this  head  may  be  classed  as  fol- 
lows :  Those  of  a  chronic  form,  with  exudations  of  pus ;  those  in 
which  hypertrophy  is  a  prominent  feature;  and  those  in  which 
there  is  breaking  down  or  degeneration.     In  the  chronic  form  of 


Fig.  23. 


A.  Diagram  of  a  lower  first  molar,  with  a  cavity  at  a  completely  filled  by  an  hypertrophy 
of  the  pulp,  which  has  grown  out  through  the  orifice,  exposing  the  pulp  at  b. 

B.  Field  illustrating  the  tissue  of  the  growth,  which  is  composed  almost  entirely  of  granu- 
lation tissue  of  a  very  primitive  type.  a.  A  covering  of  epithelium  presenting  papillae,  b. 
Epithelium  apparently  without  papillae. 

inflammation  the  pulp  is  prone  to  throw  out  additional  elements, 
and  if  this  takes  place  it  may  cause  absorption  of  the  walls  of  the 
pulp  chamber  to  an  appreciable  extent.  If  there  is  an  opening 
into  a  cavity  of  decay  the  growing  pathological  tissue  escapes 
through  that,  and  may  not  only  continue  to  increase  in  size  until 
the  cavity  of  decay  is  completely  filled,  but  the  development  may 
still  go  on  until  it  projects  from  the  cavity,  protruding  as  a  reddish 


I/O 


THE    PRACTICE    OF    DENTAL    MEDICINE. 


fleshy  mass,  tender  to  the  touch  and  bleeding  easily.  This  growth 
of  pulp  tissue  is  often  found  to  be  continuous  with  the  gum  tissue, 
and  therefore  ft  may  appear  as  if  the  gum  had  grown  into  the 
cavity,  but  upon  inspection  it  will  be  found  that  the  mass  extends 
into  the  pulp  chamber,  and  that  we  must  account  for  its  attach- 
m.ent  to  the  gum  in  some  other  way.  It  has  been  suggested  that 
abrasions  of  the  gum  occur,  and  while  presenting  a  fresh  surface 
thus  made,  the  hypertrophied  pulp  becomes  engrafted  to  the  gum 

Fig.  24. 


Chronic  inflammation  of  tlie  pulp,  areolation,  and  degeneration. 

tissue.  Black  describes  the  hypertrophied  pulp  as  ''granulation 
tissue  of  low  type"  and  gives  the  accompanying  figure  as  a  good 
illustration  of  this  condition.     (Fig.  23.) 

The  other  variety  of  low-grade  inflammation  takes  the  form 
of  degeneration,  in  which  the  original  cells  disappear.  Areolae 
develop  in  the  matrix,  which  may  or  may  not  extend  through  the 
entire  pulp  tissue.     This  condition  may  be  seen  in  Fig.  24. 


CHAPTER    XXXII. 

SUPPURATION  AND  ABSCESS  OF  THE  DENTAL  PULP. 


Definition. — While  the  term  abscess  includes  the  process  of 
suppuration,  a  distinction  is  usually  made  between  the  condition 
which  begins  in  a  destruction,  and  consequent  formation  of  pus, 
in  a  portion  of  the  surface  of  the  pulp,  and  progressing  in  area  and 
depth,  and  that  in  which  a  circumscribed  area  is  similarly  afifected, 


SUPPURATION  AND  ABSCESS   OF   THE   DENTAL   PULP.  I7I 

usually  within  the  substance  of  the  pulp.  The  former  condition  is 
termed  suppuration,  or  ulceration,  and  the  latter,  abscess. 

Etiology.- — A  suppurative  condition  of  the  dental  pulp  indicates 
a  certain  stage  of  the  inflammatory  process  (see  etiology  of  Pulpi- 
tis) dependent  directly  upon  the  entrance  of  pyogenic  organisms 
into  the  pulp  tissue.  In  order  that  this  infection  may  be  accom- 
plished, it  is  not  necessary  that  the  pulp  be  actually  exposed,  but 
in  ordinary  cases  the  carious  cavity  approaches  sufficiently  near 
the  pulp  to  cause  an  inflammation  of  this  tissue,  and  the  thin  layer 
of  intervening  dentin,  usually  in  a  state  of  decalcification,  afifords 
an  easy  entrance  to  bacteria.  The  possibility  of  the  dental  pulp 
becoming  infected  through  a  layer  of  hard  dentin,  or  indirectly, 
through  the  general  circulation,*  is  admitted,  but  such  cases,  it 
seems  to  the  writer,  must  be  rare. 

Pathology. — The  peripheral  cells  of  the  pulp  are  usually  first 
affected,  losing  their  vitality,  and  finally  breaking  down.  This 
process  may  extend  little  by  little  until  the  entire  pulp  has  yielded 
to  the  destructive  process.  The  presence  of  pus  may  be  demon- 
strated by  an  exploratory  puncture  through  an  existing  layer  of 
dentin,  or  it  may  be  seen  rhythmically  welling  through  a  small 
opening  into  the  carious  cavity;  or,  minute  abscesses  may  be  dem- 
onstrated within  the  substance  of  the  pulp  by  means  of  a  micro- 
scopic examination.  Bacteria  are,  of  course,  present  in  different 
forms,  cocci  and  diplococci  being  constantly  present.  The  variety 
of  forms  depends  somewhat  upon  the  size  of  the  pulp-exposure, 
and  the  distance  of  the  suppurative  process  from  it.f  The  follow- 
ing quotation  from  Black  J  is  of  value  in  this  connection: 

In  Fig.  25,  A,  I  have  represented  in  diagram  a  first  molar  with  a 
proximal  decay  exposing  the  pulp.  The  darkened  portion  of  the  pulp  at 
b  shows  the  extent  of  the  invasion  of  the  pulp  tissue  by  the  inflammatory 
process.  In  B  is  given  an  illustration  of  the  tissue  which  I  have  taken 
from  a  central  section,  and  which  includes  most  of  the  inflamed  area.  In 
this  I  have  left  the  bloodvessels  blank  that  they  may  be  more  apparent, 
though  in  the  section  they  are  filled  with  clotted  blood.  It  will  be  noted 
that  in  the  greater  part  of  the  field  the  normal  cells  of  the  part  have  dis- 
appeared and  have  given  place  to  inflammatory  elements,  and  that  at  the 
immediate  point  of  exposure  the  odontoblasts  are  wanting  and  the  tissue 
has  been  invaded  by  the  suppurative  process,  forming  a  deep  pocket  in  its 

*  Miller,  Dental  Cosmos  for  July  1894. 

t  For  an  exhaustive  and  interesting  article  by  Miller  upon  this  subject, 
see  Dental  Cosmos  for  July  1894. 

t  "American  Sj'stem  of  Dentistrj-,"  vol.  i.  p.  853. 


172 


THE    PRACTICE    OF    DENTAL    MEDICINE. 


substance.  The  undermining  of  the  layer  of  odontoblasts  at  the  point  b  is 
worthy  of  especial  note.  This  undermining  of  the  odontoblasts  occurs  so 
often  that  I  may  say  that  it  is  the  general  rule  in  what  may  be  called  pro- 
gressive suppuration  of  the  pulp,  which  is  the  form  that  I  have  generally 
found.  Occasionally  I  have  found  suppuration — or,  more  properly,  per- 
haps, ulceration- — following  a  very  superficial  inflammation,  in  which  the 
tissue  was  apparently  melting  down  into  a  sanious  pus  thickly  inhabited  by 

micro-organisms 

Abscess  of  the  pulp  is  of  frequent  occurrence,  and  it  seems  to  me 
probable  that  the  suppurative  process  very  often  makes  its  beginnings  in 
the  form  of  a  minute  abscess  just  within  the  layer  of  the  odontoblasts. 


Fig 


A.  Diagram  of  lower  molar,  with  caries  at  a  which  exposes  the  pulp.  The  darkened  por- 
tion at  6  shows  the  extent  of  the  inflammation.  The  rest  of  the  organ  was  free  from  inflamma- 
tory change. 

£.  Illustration  of  the  inflamed  tissue,  showing  a  part  destroyed  by  suppuration  at  a.  The 
odontoblasts  are  undermined  at  6.  The  bloodvessels  which  were  filled  with  blood-clot  in  the 
section  are  left  blank  here,  that  they  may  be  more  apparent. 

These  cells  exhibit  less  disposition  to  change  under  the  influence  of  inflam- 
mation than  do  the  other  cells  of  the  pulp,  and  I  have  often  found  them 
retaining  their  form  and  position  when  the  tissue  in  immediate  juxtaposi- 
tion with  them  had  been  destroyed.  Therefore  it  seems  probable  that  the 
first  formations  of  pus  would  be  retained  behind  them  for  a  time  in  the 
form  of  a  tiny  abscess;  at  least,  this  is  suggested  by  the  facts  observed. 

Abscesses  lying  deeper  in  the  tissue  of  the  organ  are  seen  to  form  by 
the  aggregation  of  the  inflammatory  elements  into  a  compact  mass,  or 
little  masses  that  lie  near  each  other  and  run  together  in  the  process  of 


SUPPURATION   AND  ABSCESS   OF   THE   DENTAL   PULP. 


173 


increasing.  These  cells,  on  account  of  the  unfavorable  conditions  of  their 
environment,  degenerate  into  pus-cells,  and  the  result  is  the  formation  of 
an  abscess.     Fig.  26  represents  very  fairly  a  beginning  of  the  collection  of 


Minute  inflammatory  focus  within  the  tissue  of  the  pulp,    a  a.  .\rterial  twigs,    d.  A  nerve- 
bundle,     c.  Collection  of  Ifeucocytes. 


Abscess  within  the  tissues  of  the  pulp.      The  field  includes  about  one-half  of  the  little 
pocket  of  pus.    (X  250.) 

inflammatory  elements  that  might  well  serve  as  the  nidus  of  an  abscess  if 
the  conditions  were  unfavorable  to  their  continued  vitality.  In  Fig.  27  is 
given  an  illustration  including  about  half  of  a  minute  abscess  that  I  dis- 
covered in  the  sections  of  the  pulp  of  a  central  incisor  about  midway  of  its 


174  THE    PRACTICE    OF    DENTAL    MEDICINE. 

length.     The  coronal  portion  was  suppurating,  and  the  inflammation  was 
rather  more  extended  in  its  tissue  than  is  common. 

Symptoms. — The  symptoms  are  those  which  pertain  to  the 
various  stages  of  pulpitis.  Although  extensive  suppuration  of  the 
dental  pulp  is  properly  associated  with  an  advanced  stage  of  inflam- 
mation, Miller*  states  that  a  microscopic  examination  will  reveal 
the  presence  of  pus,  even  when  pulpitis  seems  to  be  in  its  initial 
stage.  In  brief,  the  symptoms  are:  The  response  to  the  applica- 
tion of  cold  is  subnormal,  while  there  is  an  increased  reaction  to  the 
heat  test.  There  is  an  intense,  throbbing  pain,  which  rapidly  be- 
comes continuous-  and  these  symptoms  may,  in  twenty-four  hours, 
merge  into  those  of  septic  pericementitis  (inflammation  of  the 
alveolo-dental  periosteum). 

Prognosis. — Unfavorable  as  to  the  vitality  of  the  pulp,  but 
favorable  as  to  the  salvation  of  the  tooth. 

Treatment. — As  in  other  cases  of  pus-retention,  so  in  a  case  of 
confined  pus  in  the  pulp  chamber,  the  pus  should  be  evacuated  at 
the  earliest  possible  moment;  for  this  not  only  gives  great  relief 
from  pain,  but  prevents  further  destruction  of  tissue  and  the  spread 
of  infection.  After  the  flow  of  pus  has  ceased,  an  application  of  a 
solution  of  formalin  three  per  cent,  or  carbolic  acid  full  strength 
may  be  applied  to  the  pulp  exposure,  and  the  cavity  sealed  until  the 
next  da}^,  when,  if  there  is  no  pain  about  the  tooth,  and  the  pulp 
requires  further  devitalization,  a  very  minute  quantity  of  an  arseni- 
cal preparation  may  be  applied,  the  cavity  securely  closed,  and  the 
patient  dismissed  for  a  week  or  more,  as  the  case  may  be. 


.CHAPTER    XXXIII. 

PERICEMENTITIS. 

Synonyms. — Periodontitis;  Periostitis;  Alveolo-dental  periosti- 
tis. 

Etiology. — Foremost  among  the  causes  of  pericementitis  is 
death  of  the  pulp,  the  resulting  gases  of  decomposition  from  which 

*  Dental  Cosmos,  July  1894. 


PERICEMENTITIS.  1/5 

are  forced  through  the  apical  foramen,  and  by  their  irritating 
nature,  mechanical  force,  and  septic  action  set  up  an  inflammation 
at  the  end  of  the  root  which  travels  along  its  membrane  throughout 
its  entire  extent. 

We  believe  that  considerable  pressure  is  often  exerted  by  the 
forming  gases  when  there  is  no  opening  through  the  tooth  or  any 
aperture  from  a  fistula.  Indeed  it  would  be  difficult  to  account  in 
any  other  way  for  the  manner  in  which  certain  fillings  have  been 
forced  out  of  the  cavity,  following  death  of  the  pulp,  or  for  the 
splitting  of  teeth,  sometimes  with  an  audible  report. 

Pericementitis  may  also  result  from  an  injury,  as  a  blow  upon 
the  tooth;  or,  as  in  one  case  within  the  writer's  knowledge,  from 
the  accidental  heating  of  a  metal  clamp  around  a  tooth  upon  which 
a  jet  of  steam  was  directed  for  the  purpose  of  obtunding  hyper- 
sensitive dentin.  Deposits  of  calculus  or  other  foreign  substances 
beneath  the  gum  may  induce  a  chronic  pericementitis  by  im- 
pinging upon  the  cementum. 

The  loss  of  an  antagonizing  tooth,  mal-occlusion,  filling 
material  projecting  far  beneath  the  gum  or  through  the  apical 
foramen,  excess  of  filling  material  on  the  crown  surfaces  of  teeth, 
are  all  etiological  factors  in  producing  pericementitis. 

Pathology. — The  increase  in  the  force  of  the  circulation  tending 
to  engorgement  gradually  distends  the  vessels  of  the  pericemen- 
tum, and  after  a  time  swelling  of  the  membrane  is  evidenced  by  the 
protrusion  and  loosening  of  the  tooth. 

As  the  inflammatory  process  advances,  the  vessels  become 
engorged  with  blood,  leucocytes  escape  into  the  surrounding 
tissues,  and  there  is  considerable  pressure  from  the  blood  as  well 
as  from  the  infiltration  of  cells  and  other  products  of  inflammation, 
confined  as  they  are  between  bony  walls.  The  migrated  cells  col- 
lect in  small  areas  and  pus  is  formed.  Many  of  these  small  aggre- 
gations of  cells  may  coalesce  and  form  one  large  pus-cavity,  not 
deep,  but  covering  a  large  area.  Pus  is  often  formed  very  quickly, 
usually  within  three  days;  on  the  other  hand,  the  process  of  pus- 
formation  may  extend  over  a  week. 

Symptoms. — The  symptoms  of  advanced  pericementitis  are  un- 
mistakable. The  slightly  loose,  protruding  tooth,  sensitive  to  the 
slightest  touch,  but  not  painful  in  response  to  the  application  of 
heat  or  cold,  at  once  indicates  inflammation  of  the  pericementum. 

In  the  beginning  of  acute  pericementitis  the  patient  may  com- 


176  THE    PRACTICE    OF    DENTAL    MEDICINE. 

plain  of  a  dull  pain  which  can  usually  be  located  in  some  tooth; 
this  increases,  followed  by  greater  redness  of  the  gum  opposite  its 
root.  As  the  pain  increases  in  severity  it  also  becomes  more  con- 
tinuous; cold  water  held  in  the  mouth  affords  comfort  temporarily. 
While,  at  first,  pressure  on  the  tooth  relieved  the  pain,  it  is  now 
painful  to  the  slightest  touch,  and  being  slightly  protruded  it  re- 
ceives pressure  and  slight  blows  which  would  not  otherwise  come 
to  it. 

There  are  usually  no  constitutional  symptoms  as  a  result  of 
the  local  inflammation;  it  is  not  that  the  severity  of  the  pain  and 
local  derangement  is  not  sufficient  to  call  upon  the  sympathy  of 
the  whole  system,  but  the  time  is  usually  so  short  that  alveolar 
abscess  is  developed  before  the  symptoms  occur. 

In  the  chronic  form  of  pericemental  inflammation  the  symp- 
toms have  much  the  same  character,  but  are  milder  in  all  respects. 
This  chronic  condition  may  last  for  weeks. 

Diagnosis. — Sensitiveness  to  percussion,  in  all  degrees  of  se- 
verity, is  a  constant  symptomatic  aid  to  diagnosis.  It  does  not 
occur  in  hyperemia  or  inflammation  of  the  pulp.  The  pain  can 
always  be  located  in  the  tooth  affected.  It  is  even  more  contin- 
uous than  in  pulpitis;,  in  fact,  the  pain  is  constant,  although  it  is 
made  worse  by  lying  down.  Another  decisive  diagnostic  point  is 
that  pain  does  not  follow  the  application  of  heat  or  cold  to  the 
tooth.  The  facts  in  the  history  of  the  case,  the  death  of  the  pulp, 
etc.,  will  furnish  conclusive  evidence  as  to  the  character  of  the 
disease  in  question. 

Treatment. — Remembering  the  causes  of  the  condition  that 
now  calls  for  treatment,  attention  is  at  once  directed  to  the  source 
of  the  poisonous  material  and  gases — the  putrescent  pulp;  and  if 
there  is  no  outlet  for  these  through  the  crown  of  the  tooth,  one 
should  be  made  which  will  be  sufficient. 

This  done,  counter-irritation  may  be  effected  by  means  of 
capsicum  plasters,  or  a  blister  formed  by  the  application  of  some 
vesicant  to  the  gum  opposite  the  affected  root. 

Further  depletion  may  be  made  by  means  of  local  bloodletting, 
passing  a  lancet  around  the  tooth  and  under  the  border  of  the 
gum,  or  by  leeches.  (The  foreign  leeches  are  more  efficacious 
than  the  American.)  In  order  to  get  the  leech  to  take  hold,  the 
gum  should  be  clean  and  free  from  medicaments;  a  scratch  should 
be  made  at  the  point  where  it  is  desired  to  apply  the  leech,  and  the 


PERICEMENTITIS.  177 

slight  amount  of  blood  will  entice  him  on,  or  a  little  sugar  placed 
on  the  part  will  generally  accomplish  the  desired  result.  The 
leech  ought  to  take  a  dram  of  blood;  after  it  is  removed,  bleeding 
may  be  encouraged  by  wiping  away  the  clot  as  fast  as  it  forms  and 
rinsing  the  mouth  with  warm  water. 

In  severe  cases  it  often  gives  relief  to  make  an  artificial  sinus 
through  the  gum  and  alveolar  process  to  the  apical  space.  The 
writer  has  used  carbolic  acid  for  this  purpose,  in  the  manner  de- 
scribed by  Dr.  Black.  It  is  applied  to  the  dried  membrane  by 
means  of  a  plugger-point  with  prominent  and  sharp  serrations, 
dipped  in  a  ninety-five  per  cent,  solution  of  carbolic  acid,  and 
touched  with  the  point  at  the  spot  v/here  it  is  desired  to  puncture 
the  gum.  This  produces  a  white  eschar,  which  is  removed  with  the 
plugger-point  by  means  of  a  slight  scratching  motion.  This  pro- 
cess is  repeated  until  the  bone  is  reached,  when  the  periosteum  is 
carefully  raised. and  with  a  sharp  drill  an  opening  to  the  apical 
space  is  made. 

In  the  milder  forms  of  inflammation,  local  applications  may  be 
made  to  the  gum,  as  tincture  of  aconite-root  and  tincture  of  iodin, 
either  singly  or  combined. 

To  still  furtUer  deplete,  if  the  case  demands  it,  the  feet  may  be 
put  in  water  as  hot  as  can  be  borne,  adding  hot  water  from  time  to 
time  as  the  temperature  may  be  increased  much  above  that  which 
is  bearable  at  first. 

A  free  evacuation  of  the  bowels  will  still  further  deplete,  and 
this  may  be  accomplished  by  administering  calomel  one-tenth  of  a 
grain  every  hour  for  four  or  six  hours,  according  to  the  needs  of 
the  case.  If  on  the  following  morning  the  desired  action  has  not 
beeii  accomplished,  a  dessertspoonful  of  magnesium  sulphate  may 
be  given  in  a  large  glass  of  water  at  least  half  an  hour  before  break- 
fast. 

If  the  pain  is  not  very  severe  sodium  bromid  may  be  a  sufficient 
sedative.  It  may  be  administered  in  twenty-grain  doses  every  two 
hours  until  three  doses  have  been  given.  If  the  bromid  is  not 
sufficient  to  quiet  the  pain,  resort  may  be  had  to  opium  in  some 
form,  and  the  deodorized  tincture  is  well  suited  to  the  ordinary 
case.  Fifteen  drops  in  a  little  water  may  be  administered,  to  be 
repeated  in  half  an  hour  if  the  pain  is  not  relieved. 

If  there  is  any  reason  against  the  use  of  opium,  from  three  to 
ten  grains  of  antikamnia  may  be  used  as  a  substitute.     The  pow- 


178  THE    PRACTICE    OF    DENTAL   MEDICINE. 

der  should  be  placed  on  the  tongue  and  washed  down  with  a  little 
water. 


CHAPTER    XXXIV. 
DENTO-ALVEOLAR  ABSCESS. 


Definition. — An  alveolar  abscess  is  an  abnormal  circumscribed 
cavity  containing  pus,  located  within  the  alveolar  walls,  usually  in 
the  apical  space. 

Etiology. — The  majority  of  the  causes  are  traced  back  to  those 
which  we  found  to  be  the  origin  of  pericementitis,  and  back  of  that, 
to  those  which  caused  pulpitis;  and  finally,  to  those  which  caused 
hyperemia  of  the  pulp.  But  an  abscess  may  be  formed  which  is 
commonly  termed  "alveolar"  from  other  causes  than  those  included 
in  the  above-named  processes;  for  instance,  a  deposit  of  tartar, 
some  injury,  or  a  foreign  body  may  cause  an  abscess  at  the  side  of 
the  root  of  a  tooth. 

Pathology. — By  the  terms  of  our  definition  we  expect  to  find 
pus  in  the  apical  space;  this,  as  it  is  formed,  presses  upon  the 
tissues  in  all  directions,  and  as  this  pressure  increases,  absorption 
takes  place;  in  this  way  the  space  is  enlarged,  and  not  only  is  this 
so,  but  absorption  may  go  on  from  this  cause,  following  the  weak- 
est or  least  resistant  structure  until  the  pus  makes  its  escape. 

In  the  above  process  of  pressure  and  absorption  the  fibers 
of  the  pericementum  are  swollen  and  separated,  being  infiltrated 
with  inflammatory  products,  as  may  be  seen  in  the  fleshy  mass 
usually  found  at  the  end  of  the  root  after  extraction. 

We  have  stated  that  the  pus  makes  its  way  of  escape  in  the 
direction  which  ofifers  the  least  resistance  to  its  progress.  The 
direction  is  not  the  same  in  all  cases,  owing  to  the  differences  in 
structure  and  in  the  circumstances  under  which  the  abscess  devel- 
ops. For  instance,  if  there  be  a  large  crown  cavity  with  an  open- 
ing into  the  pulp  chamber  the  pus  may  escape  through  the  canal 
and  crown  of  the  tooth  into  the  mouth,  or  it  may  penetrate  directly 
through  the  alveolar  plate,  either  buccally  or  palatally,  through  the 
soft  tissues  into  the  mouth  (Fig.  28,  e),  or  it  may  not  make  its  way 
through  the  alveolar  plate,  escaping  instead  at  the  margin  of  the 


DENTO-ALVEOLAR   ABSCESS. 


179 


gum.  Or  it  may  go  through  the  process  but  not  through  the  peri- 
osteum, pushing  it  off  and  forming  a  pus-sac  of  greater  or  less 
extent.  (Fig.  28,  d.)  The  bone  in  some  cases  thus  loses  its  perios- 
teum over  a  considerable  area,  which  of  course  predisposes  it  to 
necrosis. 

The  pus  may  also  find  its  way  from  the  apical  space  into  the 
maxillary  sinus  and  thence  into  the  nose  (Fig.  28,  b),  or  it  may 
escape  by  way  of  the  palate  or  extend  into  the  pharynx;  and  finally, 
it  may  penetrate  the  soft  tissues,  forming  an  opening  on  the  face. 

The  amount  of  pus  formed  varies  with  the  condition  of  the  indi- 
vidual and  the  severity  of  the  case.  It  is  often  very  profuse,  grad- 
ually lessening  in  amount  until,  after  a  period  of  four  or  five  days, 


Fig.  28. 


a.  Maxillary  sinus,  d.  Sinus  from  an  abcess-cavity  discharging  into  the  antrum,  c.  Abcess- 
cavitj'.  d.  Pus-cavity  showing  periosteum  pushed  away.  e.  Pus-cavity  whose  sinus  extends 
through  pericementum,  alveolar  plate,  periosteum,  and  gum  tissue.  /".  Inferior  meatus  of  the 
nose. 

it  has  for  the  most  part  ceased  and  the  gum  and  surrounding  tis- 
sues resume  in  a  considerable  degree  their  normal  appearance. 
Following  this  there  is  usually  a  slight  discharge  of  pus,  which 
may  be  kept  up  indefinitely,  or  in  other  words  it  assumes  a  chronic 
condition  unless  treatment  is  instituted  to  correct  it. 

The  fistula  usually  remains  open;  sometimes  it  heals  and  then 
reopens;  and  again  it  heals  permanently,  forming  what  is  known 
as  a  blind  abscess.     (Fig.  29.) 

These  conditions  are  kept  up  by  the  slow  discharge  of  the  prod- 
ucts of  putrefaction  from  the  pulp  chamber  into  the  apical  space; 
furthermore,  these  products  are  absorbed  into  the  dentin  and  give 
rise  to  more  or  less  discoloration  of  the  tooth. 

Symptoms. — The  local  signs  and  symptoms  of  acute  alveolar 


i8o 


THE    PRACTICE    OF   DENTAL   MEDICINE, 


abscess  include  many  of  those  connected  with  the  periceqiental 
inflammation  which  has  preceded  it;  in  fact,  we  have  abscess  and 
its  symptoms  added  to  pericementitis  and  its  symptoms.  These 
additional  symptoms  are  indicated  by  the  violent  throbbing  char- 
acter of  the  pain,  which  is  now  continuous  and  which  increases 
until  it  is  wellnigh  unbearable.  The  adjacent  gum  tissue  becomes 
deeply  congested,  and  afterward  swollen,  increasing  in  fullness 
until  there  is  distinct  fluctuation,  showing  the  accumulation  of  pus 
at  this  point;  this,  if  left  to  itself,  may  be  discharged  at  the  point  of 
greatest  fluctuation. 

The  looseness  of  the  tooth  in  its  socket  increases  up  to  the  time 
when  the  pent-up  pus  escapes;  after  that  time  it  gradually  gets 
firmer,  the  pain  lessens,  and  all  symptoms  are  abated. 


Fig.  29. 


a.  Abcess-cavity. 

In  the  chronic  form  the  same  features  obtain,  although  they 
are  modified  to  a  great  extent  as  the  symptoms  become  acute  from 
time  to  time.  In  severe  cases  the  general  system  shows  its  sym- 
pathy with  the  local  disturbance  by  fever,  as  indicated  by  the  quick- 
ened pulse,  flushed  face,  hot,  dry  skin,  thirst,  coated  tongue,  con- 
stipation, loss  of  appetite,  etc. 

Prognosis. — This  depends  upon  the  advancement  of  the  inflam- 
mation before  the  beginning  of  treatment;  the  temperament;  con- 
dition of  health,  etc.  It  must  be  said  that  when  the  process  is 
fairly  begun  it  is  likely  to  run  a  certain  definite  course,  limited  by 
the  time  when  the  pus  makes  its  escape.  This  is  hastened  by  treat- 
ment. 

Diagnosis. — In  those  rare  cases  in  which  it  may  be  possible  to 


DENTO-ALVEOLAR    ABSCESS.  l8l 

confound  alveolar  abscess  with  erysipelas,  actinomycosis,  sub- 
periosteal inflammation,  impacted  teeth,  etc.,  attention  to  the 
vitality  of  the  pulp,  the  soreness  of  the  tooth  in  proportion  to  the 
acuteness  of  the  attack,  the  condition  of  the  gum,  exploration  of 
existing  sinuses,  etc.,  ought  to  furnish  conclusive  evidence  as  to 
the  existence  or  not  of  alveolar  abscess. 

Treatment. — While  the  treatment  is  to  be  modified  according  to 
the  symptoms  and  stage  of  the  morbid  process,  there  are  certain 
general  principles  to  be  observed,  viz.  the  discharge  of  pus  and  the 
relief  of  pain,  and  depletion  by  local  and  general  means. 

In  the  evacuation  of  the  pus,  the  usual  procedure  is  to  lance 
freely  the  soft  and  most  prominent  point  of  the  swelling,  and  at 
the  same  time,  if  possible,  to  favor  drainage  by  making  the  open- 
ing at  the  most  dependent  part. 

The  tooth  is  usually  so  painful  to  the  touch  that  it  is  with  great 
difficulty  that  an  opening  can  be  made  into  the  pulp  chamber, 
although  it  may  be  desirable  to  make  such  an  opening.  It  may  be 
helpful  in  such  cases  to  tie  a  ligature  around  the  affected  tooth, 
and  make  traction  upon  it  in  the  opposite  direction  to  that  in  which 
the  drill  is  being  pushed.  There  is  often  such  pressure  in  the 
apical  space  that  when  the  opening  is  made  into  the  pulp  chamber 
the  pus  comes  out  profusely,  and  rapidly  fills  the  opening,  giving 
relief  from  pain  at  once. 

In  worthless  roots  and  in  rare  cases  of  general  weakness  it  is 
best  to  extract  the  offending  organ. 

After  the  discharge  of  pus  and  the  consequent  relief  from  pain, 
the  patient  may  usually  be  discharged  until  soreness  of  the  tooth 
has  ceased,  when  the  tooth  may  be  treated.  The  treatment  of  the 
pain,  and  depletion  by  leeches  and  cathartics  in  the  early  stages,  is 
precisely  the  same  as  in  pericementitis. 

The  majority  of  cases  will  need  no  further  treatment.  In  the 
early  stages  quinin  in  six-grain  doses  every  four  hours  may  be  indi- 
cated in  order  to  limit  pus-formation. 

After  the  active  symptoms  subside,  certain  cases  should  receive 
treatment  calculated  to  strengthen  the  nervous  system  and  enrich 
the  blood.  Strychnin  or  nux  vomica  may  be  relied  upon  as  a  nerve 
tonic,  while  the  arsenate  of  iron  in  pill  form  may  be  administered 
in  anemic  conditions. 

This  treatment  is  also  applicable  to  many  conditions  found  in 
the  chronic  form  of  alveolar  abscess. 


l82  THE    PRACTICE    OF    DENTAL   MEDICINE. 

CHAPTER    XXXV. 

DENTAL  EROSION. 

Definition. — A  gradual  wasting  away  of  certain  portions  of  the 
teeth,  probably  due  to  chemical  action. 

Etiology. — From  the  time  of  Hunter  until  the  present  day, 
various  etiological  factors  have  been  entertained,  some  of  which 
may  be  briefly  stated  as  follows:  An  inherited  condition  of  the 
teeth,  not  dependent  upon  local  influences  or  accidental  causes;  an 
imperfect  formation  of  the  enamel;  and  mechanical  action,  princi- 
pally that  of  the  tooth-brush.  Many  writers  have  expressed  their 
belief  in  the  causal  relation  of  hyperacidity  of  the  saliva  to  dental 
erosion,  and  especially  has  Dr.  James  Truman*  given  much  atten- 
tion to  this  subject,  maintaining  for  many  years  that  erosion  of 
the  teeth  was  caused  by  the  acid  resulting  from  fermentation  in  the 
mouth. 

His  experiments  were  made  with  the  object  of  testing  the  oral 
fluids  at  different  times  during  the  day  and  night,  and  he  found 
that  the  greatest  acidity  was  attained  after  a  prolonged  period  of 
rest,  this  time  being  in  the  early  morning  hours. 

Working  in  the  same  direction,  Dr.  E.  C.  Kirkf  not  only  con- 
firmed the  tests  made  by  Dr.  Truman,  but  suggested  the  source  of 
the  acid,  showing  by  tests  with  litmus  paper  that  the  mucous 
glands  of  the  lip,  or  cheek,  opposite  the  eroded  surface,  secreted 
an  abnormal  product  which  exerted  a  solvent  action  on  the  teeth. 
The  writer  may  add  that  he  has  applied  the  test  as  suggested  above 
for  several  years,  and  his  experience  leads  him  to  concur  in  the 
statements  made  by  Dr.  Kirk.  The  conclusions  as  to  cause,  re- 
sulting from  these  demonstrations  are  maintained  at  the  present 
time;  indeed,  it  would  be  difficult  to  account  for  many  eroded  sur- 
faces located  in  odd  situations  where  mechanical  influences  cannot 
act,  were  it  not  for  the  supposed  abnormal  action  of  certain  isolated 
glands  which  are  affected.  Among  the  causes  which  probably  act 
both  locally  and  systemically  are  the  excessive  use  of  acid  fruits 
and  drinks.     Several  cases  illustrating  the  injurious  action  of  these 

*  International  Dental  Journal,  vol.  xiv.  No.  4. 
t  Dental  Cosmos,  1886. 


DEXTAL    EROSION.  1 83 

agents  have  been  reported,  and  the  writer  has  seen  two  or  three 
cases  in  which  they  were  prominent  factors  in  producing  dental 
erosion.  Dr.  Michaels  of  Paris  has  made  some  experiments* 
which  were  described  by  Dr.  Bogue  at  a  meeting  of  the  New  York 
Odontological  Society  in  June,  1894.  Dr.  Michaels  asserted  that 
potassium  sulphocyanid  would  produce  an  erosion  of  the  teeth 
having  the  same  appearance  as  that  found  in  the  mouth.  In  a 
similar  experiment  performed  by  Dr.  Sogue  the  teeth  thus  acted 
upon  showed  distinct  marks  of  erosion  after  four  days.  Dr.  Bogue 
said  that  potassium  sulphocyanid  gave  a  slightly  acid  reaction  to 
litmus  paper  after  it  had  been  lying  wet  all  night.  These  experi- 
ments are  appropriate,  inasmuch  as  potassium  sulphocyanid  is 
found  in  the  saliva,  but  in  no  other  part  of  the  body. 

Constitutional  conditions,  inherited  usually,  but  often  acquired, 
certainly  play  an  important  part  in  the  causation  of  dental  erosion. 
This  statement  is  made,  however,  knowing  that  it  is  at  present 
impossible  to  exactly  define  either  the  constitutional  condition  or 
the  manner  in  which  it  produces  the  special  lesion  in  the  mouth; 
but  clinically,  for  the  past  ten  years,  there  has  been  observed  a 
condition  of  the  general  system  loosely  termed  a  gouty  diathesis 
which  has  been  constantly  associated  with  erosions  of  the  teeth, 
often  involving  both  the  gum  tissue  and  the  alveolo-dental  peri- 
osteum. It  is  also  the  writer's  belief,  based  on  clinical  observa- 
tions including  an  examination  of  oral  secretions  and  renal  excre- 
tions, that  what  is  termed  phagedenic  pericementitis  is  but  an 
acute  stage  of  the  condition  in  which  there  is  loss  of  tooth  sub- 
stance (erosion),  gum  tissue,  and  alveolo-dental  periosteum,  with- 
out pus,  calculus,  or  inflammatory  conditions. 

That  erosions  of  the  teeth  have  been  observed  to  exist  inde- 
pendently of  any  symptoms  of  a  gouty  diathesis  is  probably  due  to 
the  fact  that  such  a  diathesis  may  exist  for  years  without  producing 
marked  symptoms,  and  that  certain  symptoms,  as  neuralgia,  are 
often  overlooked,  as  far  as  the  relation  to  a  gouty  condition  is  con- 
cerned. 

Prognosis. — The  prognosis  is  discouraging,  yet  it  is  not  always 
hopeless,  depending  upon  the  general  condition  of  the  body,  which 

*  The  experiments  consisted  in  dropping  upon  a  tooth  a  solution  of 
potassium  sulphocyanid  i  part,  to  water  1000  parts.  It  was  effected  b}' 
means  of  two  capillary  siphons,  one  drawing  the  solution  and  the  other 
carrying  it  away. 


184  THE    PRACTICE    OF    DENTAL    MEDICINE. 

in  some  cases  is  such  that  the  disease  is  arrested  or  mitigated,  while 
in  others  it  is  so  rapidly  progressive  that  the  destruction  of  the 
involved  teeth  is  threatened. 

Symptoms  and  Diagnosis. — Erosion  is  to  be  distinguished  from 
abrasion  by  the  shape  of  the  eroded  surface  (Fig.  30)  and  its  polish, 
and  by  its  location  in  territory  which  is  not  acted  upon  by  opposing 
teeth  or  necessarily  by  the  tooth-brush.  It  is  usually  located  on 
the  labial  and  buccal  surfaces  of  the  incisors,  cuspids  and  bicuspids, 
and  sometimes  on  the  molars,  at  the  junction  of  the  gum  margin 
with  the  enamel.  The  erosion  of  grinding  surfaces  may  be  dis- 
tinguished from  abrasion  by  the  peculiar  cup-shaped  depressions, 
not  conforming  to  the  flat  surface  or  the  point  of  contact  with  the 
opposing  tooth.  A  careful  examination  of  the  secretion  from  the 
mucous  follicles  of  the  lips  opposite  the  eroded  surfaces  will  usually 

Fig.  30. 


Eroded  teeth. 

show  a  decided  acid  reaction.  This  examination  may  be  made  by 
drying  the  mucous  surface  and  applying  litmus  paper  thereon, 
pressing  the  tissue  to  cause  an  outflow  of  the  secretion.  The  test 
should  be  made  in  the  morning,  on  rising,  and  at  other  times 
during  the  day. 

While  erosion  may  exist  without  the  patient's  being  conscious 
of  any  systemic  disturbance,  a  careful  physical  examination  will 
usually  reveal  a  gouty  or  rheumatic  condition. 

Treatment. — The  treatment  of  erosion  may  be  classified  under 
three  heads:  ist.  Filling  the  eroded  cavities.  2d.  Local  applica- 
tions as  a  preventive.  3d.  Constitutional  treatment,  both  preven- 
tive and  curative. 

Filling  the  eroded  cavities  or  depressions  is  to  be  comrnended 
in  cases  sufficiently  advanced,  but,  as  one  may  readily  perceive,  it 
only  prevents  further  action  in  that  particular  direction;  it  does  not 
eradicate  the  cause,  and  erosion  may  still  go  on  in  other  parts  of 
the  tooth  surrounding  the  filling. 


DENTAL    EROSION.  185 

Regarding  local  applications,  the  main  object  is  to  neutralize 
the  acid  secretions  and  form  a  protective  coating  over  the  surfaces 
exposed  to  their  action.  One  of  the  most  recent  and  effective 
means  of  accomplishing  this  was  suggested  by  Dr.  E.  C.  Kirk.* 
It  consists  in  taking  into  the  mouth  about  a  teaspoonful  of  an  un- 
ofificial  preparation  known  as  "milk  of  magnesia"  (magnesium  hy- 
drate) and  letting  it  flow  over  the  teeth.  This  forms  a  thin  coating 
over  them,  protecting  their  surfaces  and  rendering  the  saliva  alka- 
line for  some  hours.  It  should  be  done  more  especially  after 
brushing  the  teeth  at  bedtime,  and  immediately  after  brushing  the 
teeth  in  the  morning. 

A  preparation  which  has  been  used  with  good  effect  is  one 
composed  of  precipitated  chalk,  sodium  bicarbonate,  and  gum 
tragacanth.  these  forming  a  sticky  paste  which  adheres  to  the 
tooth. 

The  constitutional  treatment  must  of  necessity  varv  with  the 
constitutional  need,  as  far  as  this  can  be  ascertained.  Examina- 
tion of  the  blood,  urine,  and  oral  secretions,  essential  in  many  other 
diseases,  is  especially  so  in  this.  If  erosion  be  due  to  gout,  it  may 
not  be  simple  gout,  and  if  not,  complications  must  be  taken  into 
consideration.  If  the  assertions  of  recent  writers  are  true,  that 
erosion  of  the  teeth  is  due  to  a  gouty  diathesis,  and  that  this  con- 
dition depends  upon  an  accumulation  in  the  blood-serum  of  the 
salts  of  uric  acid,  then  treatment  must  consist  in  removing,  if  pos- 
sible, the  conditions  which  bring  about  this  accumulation.  Al- 
though the  reasonable  and  principal  basis  of  treatment  would  seem 
to  be  the  proper  arrangement  of  the  diet,  yet  the  different  chemical 
changes  which  the  food  undergoes  are  so  complex  and  inaccessible 
that  many  of  them  are  unknown  at  the  present  time.  It  is  gen- 
erally advised  that  subjects  of  a  gouty  diathesis  should  avoid  an 
albuminous  diet,  and  partake  largely  of  farinaceous  and  vegetable 
foods;  but  Dr.  H.  W.  Draper,  in  Pepper's  "System  of  JNIedicine," 
says  that  it  is  his  experience  that  this  theory  is  not  supported  by 
the  clinical  history  of  cases,  although  it  may  be  a  legitimate  deduc- 
tion, in  view  of  the  uric  acid  theory  of  gout.  Dr.  Draper  has 
noticed  that  gouty  subjects  do  not  easily  digest  the  carbohydrates, 
sugars  and  starches,  and  that  these  foods  are  more  likely  to  pro- 
duce digestive  disturbances  than  the  albuminous  foods.  In  the 
absence  of  positive  knowledge  in  regard  to  chemical  changes  in- 

*  Dental  Cos)iios  for  July  1893,  p.  585. 


l86  THE    PRACTICE    OF    DENTAL    MEDICINE. 

volved  in  the  conversion  of  food  into  the  various  tissues  and  in  the 
formation  of  excrementitious  matters,  it  is  not  surprising  that 
authors  differ  as  to  what  should  constitute  the  diet  of  the  gouty 
subject,  although  there  is  general  agreement  that  saccharine  sub- 
stances and  malt  liquors  should  be  avoided.  In  the  matter  of 
meats,  it  should  depend  upon  the  condition  and  habits  of  the  indi- 
vidual. If  considerable  exercise  is  taken,  and  much  water  drunk, 
the  amount  of  meat  could  manifestly  be  increased.  As  a  rule, 
fresh  meat  may  be  taken  once  a  day,  preference  being  given  to 
fowl,  game,  and  white  meats,  while  salted  meats,  such  as  pork  and 
ham,  are  to  be  avoided. 

Bartholow  says  that  eggs  should  be  avoided,  as  well  as  cake, 
pastry,  and  all  saccharine  foods.  Some  writers  allow  fruits,  while 
others  restrict  or  forbid  them;  but  this  should  probably  depend 
upon  the  kind  of  fruit,  and  its  previous  effect'  upon  the  patient. 
Oranges  and  grape-fruit  often  contain  much  acid,  and  may  do 
harm  locally  and  constitutionally.  Vegetables,  milk,  fish,  and  oys- 
ters may  be  allowed,  but  potatoes  and  other  starchy  foods  should 
be  restricted. 

The  objective  points  toward  which  the  medicinal  treatment  of 
the  gouty  dyscrasia  is  aimed  are  classified  as  follows  by  Dr. 
Draper:  ist.  The  improvement  of  the  primary  digestion.  2d. 
The  relief  of  the  gastro-intestinal  catarrh,  which  is  the  cause  of  the 
direct  and  reflex  dyspeptic  symptoms  which  belong  to  this  diath- 
esis. 3d.  The  augmentation  of  food-oxidation,  so  as  to  secure 
its  thorough  combustion.  4th.  The  promotion  of  the  elimination 
of  the  waste  products  of  nutrition. 

In  regard  to  the  first — viz.  the  improvement  of  the  primary 
digestion — attention  to  the  diet  and  exercise  as  before  mentioned, 
the  judicious  use  of  pepsin  fifteen  minutes  before  meals,  and  pan- 
creatin,  which  aids  in  the  digestion  of  the  fatty  amylaceous  and 
ozotized  foods,  are  mainly  to  be  relied  upon. 

In  regard  to  the  second  proposition,  we  refer  to  the  remarks 
on  diet  and  exercise,  and  in  addition  commend  the  mineral  waters, 
such  as  Carlsbad,  Friederichshall,  and  Hunyadi.  Their  use  should 
not  be  continued  over  a  long  period  of  time,  especially  in  weak, 
anemic  persons. 

The  third  objective  point  may  be  approached,  as  with  the 
others,  by  the  suggestion  of  sufficient  outdoor  air  and  exercise, 
with  a  regulated  diet.  If  the  patient  be  anemic,  the  blood  may  be 
enriched  by  the  use  of  iron  in  the  form  of  Blaud's  pills. 


ABRASION.  187 

Fourthly,  in  the  ehmination  of  the  waste  products  of  nutrition, 
remedies  which  will  increase  the  action  of  the  kidneys,  and  if  pos- 
sible act  as  solvents  of  uric  acid,  are  indicated.  The  granular 
effervescent  citrate  of  lithium  may  be  used  to  effect  this  object  and 
to  produce  an  alkaline  condition  of  the  blood.  Tartarlithine 
(lithium  bitartrate),  is  also  an  excellent  remedy  for  this  purpose. 
The  time  for  administering  these  or  other  remedies  depends  upon 
the  object  to  be  accomplished.  To  neutralize  acidity  in  the  stom- 
ach the  remedy  should  be  given  immediately  after  meals,  but  for 
the  purpose  of  exercising  a  solvent  action  it  should  be  administered 
three  or  four  hours  after  meals. 

Large  quantities  of  water,  especially  hot  water — for  its  solvent 
action,  as  a  diluent,  and  to  assist  in  elimination — are  to  be  recom- 
mended, and  should  be  taken  immediately  after  rising  and  at  other 
times  during  the  day. 


CHAPTER    XXXVI, 
ABRASION. 


Definition. — A  wearing  away  of  the  teeth  due  to  mechanical 
causes. 

Etiology. — It  is  easy  to  see  how,  by  a  disarrangement  of  the 
articulating  surfaces,  the  prominences  or  cusps  which  normally  lit 
into  corresponding  depressions  in  the  opposite  teeth  are  made  to 
antagonize  the  cusps  instead,  and  how,  these  being  worn,  still 
greater  freedom  is  given  to  the  sliding  movement  of  the  jaws  by 
which  the  articulation  is  constantly  changed.  These  changes  in 
the  articulation  may  also  be  the  result  of  defective  development,  or 
the  arrest  of  development  consequent  upon  the  extraction  of  sev- 
eral teeth  before  the  growth  of  the  jaw  is  complete.  For  instance, 
when  teeth  are  removed  from  the  upper  jaw  only,  and  the  lower 
one  goes  on  developing,  the  incisors  and  cuspids  of  both  jaws  may 
occlude,  and  are  thus  worn  or  abraded,  sometimes  in  a  marked 
degree,  being  occasionally  worn  down  to  the  gum.  Perhaps  one 
of  the  most  frequent  causes  of  abrasion  is  the  loss  of  the  molars, 
or  the  molars  and  bicuspids,  from  each  jaw,  by  which  the  remain- 


lOS  THE    PRACTICE    OF    DENTAL    MEDICINE. 

ing  anterior  teeth  are  abraded  from  excessive  use.  Smokers  have 
their  teeth  abraded  corresponding  to  the  position  in  which  the  pipe 
is  habituahy  held.  Those  addicted  to  chewing  tobacco  often 
have  ah  their  teeth  more  or  less  abraded  on  account  of  gritty  sub- 
stances contained  in  the  tobacco. 

A  certain  amount  of  wear  is  unavoidable,  and  is  therefore  not 
to  be  considered  as  an  abnormal  condition;  for  it  is  a  matter  of 
everyday  observation  that  recently  erupted  incisor  teeth,  in  nearly 
all  cases,  present  a  serrated  cutting  edge,  while  those  which  have 
been  subjected  to  wear  for  several  years  do  not  show  these  little 
prominences. 

Pathology. — The  pathological  changes  resulting  from  mechani- 
cal abrasion  are  slight,  and  very  little  has  been  said  or  written  on 
this  branch  of  the  subject. 

The  supposition  that  abraded  dentin  is  much  harder  than  nor- 
mal dentin  is  untrue,  for  any  polished  surface  may  present  the  ap- 
pearance of  greater  density  and  hardness.  This  is  well  illustrated 
in  a  polished  marble  slab,  which  resists  the  penetration  of  a  sharp 
instrument  to  a  remarkable  degree,  but  which,  as  every  one  knows, 
is  neither  denser  nor  harder  in  structure  than  before  it  was  pol- 
ished. 

The  sensitiveness  of  these  abraded  surfaces,  from  constant  irri- 
tation, may  well  provoke  changes  in  the  pulp  itself. 


CHAPTER    XXXVII. 

HYPERCEMENTOSIS. 


Synonyms. — Hyperostosis;  Exostosis;  Dental  osteoma;  Hyper- 
trophy of  the  cementum;  Excementosis. 

Definition. — Hypercementosis  is  an  excessive  development  of 
the  dental  cementum. 

Etiology. — It  13  generally  understood  that  increase  of  the 
cemental  tissue  is  due  to  some  form  of  irritation,  but  as  to  the 
exact  forms  of  irritation,  and  their  origin,  opinions  are  either  silent 
or  divided. 


HYPERCEMENTOSIS.  189 

Caries  has,  for  a  long  time,  been  mentioned  as  a  cause,  but  it 
has  not  yet  been  demonstrated  as  such. 

Various  forms  of  irritation  commonly  seen  in  the  mouth  may 
cause  hypercementosis,  such  as  mal-occlusion  of  teeth,  protrusion 
of  fillings  into  the  gum  tissue,  large  metallic  fillings  near  the  pulp, 
dep'osits  of  tartar,  etc.,  but  as  none  of  these  can  be  verified  by  sta- 
tistical tabulation  or  demonstration  the  matter  is  still  unsettled, 
although  these  propositions  may  all  be  correct. 

In  regard  to  the  increase  of  the  cemental  tissue  in  connection 
with  alveolar  abscess.  Dr.  Barrett*  says:  "In  the  case  of  roots 
that  have  long  been  in  an  abscessed  condition  it  will  be  found  that 
where  the  pericementum  has  been  destroyed  there  will  be  no  hyper- 
trophy, but  upon  those  parts  of  the  root  which  still  retain  their 
attachment  a  considerable  growth  will  not  unfrequently  be  seen. 
The  abnormal  deposition  of  cementum  is  not  dependent  upon  the 
vitality  of  the  tooth  pulp,  in  fact  it  seems  most  excessive  in  teeth 
that  have  long  been  devitalized." 

The  opposite  opinion  is  expressed  by  the  late  Prof.  Abbott,  t 
as  follows:  "Only  an  irritation  of  the  pericementum  while  the 
pulp  is  living  can,  in  my  judgment,  result  in  an  increased  cemen- 
tum." 

Dr.  Guilford  w^ell  says,  in  this  connection:  "While  hyper- 
trophy of  the  cementum  is  found  in  connection  with  teeth  that 
have  long  been  devitalized,  or  are  partially  invested  with  an  ab- 
scess-sac, we  do  not  know  that  these  conditions  in  any  way  influ- 
ence the  increase  of  tissue.  So,  too,  the  fact  that  teeth  that  have 
long  been  unantagonized  are  upon  extraction  found  to  be  largely 
exostosed,  does  not  prove  that  their  abnormality  is  due  either  to 
lack  of  antagonism  or  to  gravitation,  for  they  may  have  been  hy- 
pertrophied  before  the  latter  conditions  existed." 

Pathology. — The  teeth  most  frequently  affected  are  the  molars 
and  bicuspids,  and  it  is  said  that  the  upper  teeth  are  more  likely 
to  be  attacked  than  the  lower. 

The  disease  has  no  preference  for  any  particular  part  of  the 
root,  and  the  additional  growth  may  present  itself  in  different 
forms.  It  may  vary  in  size  from  a  microscopic  speck  to  a  growth 
which  entirely  covers  the  root  itself. 

*  Independent  Practitioner,  vol.  vii.  p.  412. 

t  "American  System  of  Dentistry,"  vol.  iii.  p.  431. 


190  ~  THE    PRACTICE   OF    DENTAL   MEDICINE. 

The  following  description  of  the  manner  of  the  formation  of 
this  growth  is  given  by  Dr.  S.  H.  Guilford:* 

Secondary  or  hyperplastic  cementum,  like  the  normal  cementum 
formed  earlier,  is  the  product  of  the  peridental  membrane  or  perice- 
mentum. This  membrane  comprises  that  tissue  which  intervenes  between 
the  root  of  the  tooth  and  the  bony  walls  of  the  alveolar  process,  and  is  the 
agent  by  which  both  these  hard  tissues  are  produced.  That  portion  of  it 
lying  next  to  the  alveolus  produces  bone,  while  the  opposite  margin,  next 
to  the  root,  is  directly  instrumental  in  the  upbuilding  of  the  cementuin. 
The  fact  that  the  same  tissue  is  capable  ^f  producing  two  hard  tissues  in 
most  respects  similar,  and  yet  dissimilar  enough  to  prevent  their  union, 
has  led  many  to  infer  that  the  peridental  membrane  is  in  reality  two  mem- 
branes lying  in  close  proximity  and  measurably  connected,  yet  differing 
the  one  from  the  other  in  certain  functional  peculiarities.  Later  investi- 
gation, however  (notably  that  of  Prof.  Black),  goes  to  show  that  the 
membrane  is  single,  and  so  constituted  as  to  be  able  to  produce  either 
bone  or  cementum  according  to  location  and  required  needs. 

Both  surfaces  of  this  membrane  are  covered  with  specialized  cells 
which  are  the  immediate  instruments  in  the  formation  of  bony  tissue. 
Those  on  one  surface,  which  are  to  produce  bone,  are  termed  osteoblasts, 
while  those  next  to  the  tooth  are  known  as  cementoblasts.  When  either 
hard  tissue  is  to  be  formed  these  special  cells  become  active  in  throwing 
out  calcareous  salts,  which  shortly  surround  them  with  spherules  of  lime. 
These  spherules,  lying  in  close  proximity,  become  coalesced  and  gradually 
filled  up  by  further  calcareous  elimination,  so  as  to  form  a  layer  of  osseous 
tissue.  Another  row  of  cells  similar  to  the  first  is  then  produced  on  the 
surface  of  the  membrane,  which  in  turn  become  converted  into  an  osseous 
layer  overlying  the  first.  In  this  way,  layer  by  layer,  the  hard  tissue 
is  produced  until  the  normal  limit  is  reached. 

In  the  formation  of  the  primary  cementum  the  first  layer  is  attached 
to  the  peripheral  surface  of  the  dentin.  On  this  the  second  layer  is  formed, 
and  so  on  until  the  normal  quantity  is  formed,  after  which  the  perice- 
mentum becomes  functionally  inactive,  and  so  remains  unless  again  called 
into  use  through  pathological  influences. 

In  the  production  of  hyperplastic  cement  the  peridental  membrane  re- 
sumes its  former  activity,  and  new  tissue  similar  to  the  first  is  added  to 
that  already  formed.  This  action  may  be  localized  or  general,  according 
to  the  conditions  operative  in  bringing  it  about.  In  the  one  case  the  new 
growth  is  circumscribed  [Fig.  31],  and  in  the  other  dififused  [Fig.  32].  In 
either  case  it  may  assume  considerable  proportions,  in  many  instances  re- 
sulting in  the  coalescence  of  the  different  roots  of  the  molar  teeth  [Fig. 
33],  and  sometimes  in  uniting  the  roots  of  adjacent  teeth.  When  this 
takes  place  one  or  more  of  the  roots  is  increased  in  size  by  the  hyper- 
plastic growth,  the  pericementum  is  distended,  the  adjoining  alveolar  sep- 
tum is  absorbed,  and  finally,  through  compression,  the  membrane  itself  is 
dissolved  and  the  roots  united. 

*  "American  System  of  Dentistry,"  vol.  iii.  p.  429. 


HYPERCEMENTOSIS. 


191 


One  of  the  most  remarkable  characteristics  of  this  peridental  mem- 
brane is  the  power  it  possesses  of  being  the  agent  of  either  the  upbuilding 
or  resorption  of  the  adjacent  bony  tissue.  At  times  it  assumes  the  one 
function,  at  other  times  the  other.  In  many  cases  the  normal  cementum 
has  been  absorbed  at  certain  points,  and  this  resorption  has  again  been 
followed  by  new  cemental  formation  in  the  same  place. 

This  resorption  of  bone  or  cementum  is  directly  brought  about  by 
special  cells  on  the  surface  of  the  pericementum,   known  as  osteoclasts. 

Fig.  31. 


^.~-^*vji**- 


These  appear  to  excrete  a  liquid  capable  of  dissolving  away  the  hard 
tissue.  Whether  these  cells  are  the  original  cementoblasts  pathologically 
modified,  or  an  entirely  new  formation,  has  not  yet  been  definitely  deter- 
mined. 

This  hypertrophic  formation,  when  magnified,  presents  grooves 
and  pits  with  portions  of  the  periosteum  attached.  Its  color  is 
usually  lighter  than  the  original  formation  and  often  is  nearly 
white.  The  excessive  growth  often  encroaches  upon  the  canal  at 
the  apex  of  the  root,  and  thus  interferes  with  the  function  of  the 
nerves  and  arteries  entering  at  this  point;  indeed,  severe  neuralgia 
may  be  the  result  of  this  encroachment  and  consequent  irritation. 

Cemental  hypertrophy  is  uncommon  in  the  incisors  and  cus- 
pids; occasionally,  however,  this  increase  of  tissue  may  be  observed 
on  the  upper  incisors  or  cuspids.  More  frequently  are  the  bicus- 
pids affected,  and  these  more  frequently  show  what  is  termed  the 
cap-shaped  variety. 

In  the  molars  the  roots  are  often  united  by  the  overgrowth,  and 
especially  may  this  be  seen  in  the  third  molar. 


192  THS    PRACTICE    OF    DENTAL    MEDICINE. 

CHAPTER    XXXVIII. 

SECONDARY  DENTIN. 

Definition. — Secondary  dentin  is  the  product  of  a  continued 
development  of  dentin  beyond  the  usual  limit,  at  the  expense  of 
the  pulp  cavity. 

The  causes  of  this  growth  are  similar  in  character  to  those 
which  produce  the  pulp  nodule;  for  example,  the  presence  of  large 
metallic  fillings  too  near  the  pulp;  the  irritation  resulting  from 
slowly  progressing  caries;  also  that  from  abraded  and  eroded 
teeth.  These  or  other  similar  causes  irritate  the  pulp  through  the 
dentinal  canals,  and  if  this  irritation  is  long  continued  it  results  in 
the  development  of  dentin  as  above  defined. 

Pathology.- — The  pulp  chamber  diminishes  in  size  as  the  walls 
of  the  dentin  increase  in  thickness ;  but  this  is  the  case  as  the  dentin 
is  normally  developed  from  childhood,  when,  as  we  know,  the  pulp 
chamber  is  comparatively  large.  It  is  not  known  when  or  upon 
what  physiological  conditions  this  growth  is  limited,  but  it  is 
known  that  when  some  abnormal  condition  obtains  which  induces 
a  further  growth  of  dentin  there  is  a  line  of  demarcation  between 
the  normally  developed  dentin  and  that  which  is  the  result  of  some 
abnormal  condition.  There  is  usually  a  general  disturbance  in  the 
formation  of  "the  dentinal  canals,  and  in  their  direction,  but  this 
varies  greatly  in  different  cases.  Generally,  in  secondary  dentin 
which  is  due  to  abrasion  or  caries  the  new  canals  correspond  in  a 
considerable  degree  with  the  old;  but  in  the  concentrically  lami- 
nated and  the  nodulated  varieties  the  canals  do  not  have  this  simi- 
larity in  direction.  The  color  of  the  new  growth  is  easily  dis- 
tinguished from  that  of  the  original  dentin. 

That  secondary  dentin  may  continue  to  be  formed  until  the  pulp 
chamber  is  entirely  occluded  has  been  demonstrated  by  observing 
patients  whose  teeth  had  been  worn  to  the  gum  margin,  yet  show- 
ing no  trace  of  the  pulp  cavity;  this  is  not  always  the  case,  how- 
ever, the  amount  of  secondary  formation  being  governed  by  the 
amount  of  irritation  and  the  time  during  which  it  has  been  in 
operation. 

It  is  also  to  be  noted  that  the  location  of  the  secondary  deposit 


rULP    NODULES,  I93 

is  related  closely  to  the  site  of  the  external  lesion;  for  example,  if 
the  dentinal  deposit  is  due  to  abrasion  long  continued,  the  result- 
ing growth  is  symmetrical,  while  that  due  to  caries  is  found  in  that 
portion  of  the  pulp  chamber  nearest  the  carious  cavity. 


CHAPTER    XXXIX. 

PULP  NODULES. 

Synonyms. — Pulp  nodules;  Pulp-stones;  Odontomes;  Denticles; 
Odontheles. 

Definition. — A  very  hard  formation  of  bone,  dentin,  or  both, 
Avithin  the  pulp  tissue,  or  attached  to  the  walls  of  the  pulp  chamber. 

Etiology. — We  have  a  record  of  observations  regarding  the 
above-named  formation  which  extends  as  far  back  as  1780,  or  pos- 
sibly earlier,  also  writings  by  Tomes  in  1846,  since  which  time 
much  has  been  written  on  this  subject;  yet  the  etiology  is  still 
obscure  as  to  the  precise  manner  of  the  formation  of  the  pulp 
nodule. 

The  observations  of  the  early  writers  led  them  to  believe  that 
so-called  ''pulp-stones"  were  a  form  of  secondary  dentin  produced 
from  the  odontoblastic  layer,  and  connected  with  the  wall  of  the 
pulp  chamber  by  a  pedicle  which  was  subsecjuently  absorbed. 
These  views,  however,  have  been  disproved  through  the  later  re- 
searches of  Miller,  Black,  Bodecker,  Baume,  and  others,  showing 
that  these  formations  occur  within  the  connective  tissue  of  the  pulp 
by  means  of  the  calcification  of  the  bundles  of  fibers  and  spindle- 
shaped  cells  of  which  it  is  composed,  and  that  they  have  no  con- 
nection with  the  odontoblasts.* 

It  is  not  certain  whether  the  spindle-cell  itself  becomes  cal- 
cified, or  the  material  is  deposited  around  the  cell,  which  thus 
becomes  enlarged  by  accretions.  Dr.  Black  says  that  these  de- 
posits are  "not  calcifications  of  the  tissue  of  the  pulp,  but  are 
found  in  the  midst  of  the  tissue,  making  room  for  themselves  by 
pushing  the  tissue  aside,"  but  Dr.  R.  R.  Andrews  is  certain  that 
these  nodules  are  calcified  from  the  connective-tissue  cells  of  the 

'^  See  paper  by  Dr.  E.  C.  Kirk,  International  Dental  Joiinwl,  December  1893. 

14 


194  THE    PRACTICE    OF    DENTAL   MEDICINE. 

pulp.  We  know  that  the  normal  deposit  of  bone,  dentin,  and 
enamel  is  self-limited,  and  in  health  remains  within  this  limitation, 
but  different  forms  of  irritation  induce  a  renewal  and  possibly  a 
perversion  of  this  function,  resulting  in  the  vaiious  hard  forma- 
tions within  the  pulp  chamber.  The  forms  of  irritation  which 
cause  this  disturbance  are  much  the  same  in  some  cases  as  those 
which  induce  deposits  about  the  joints,  in  the  coats  of  the  arteries, 
in  the  brain  and  other  parts  of  the  body.  The  casual  irritation 
may  be  general  or  local.  It  is  possible  that  syphilis,  gout,  or 
rheumatism  may  act  as  a  general  irritating  cause  of  the  deposits, 
although  this  has  not  been  proved.  Among  the  probable  local 
causes  are  caries,  excessive  abrasion,  lack  of  occluding  teeth,  reces- 
sion of  gums  and  absorption  of  the  alveolar  process,  large  metallic 
fillings,  etc. 

Dr.  Wm,  P.  Cooke  of  Boston,  in  an  examination  of  five  thou- 
sand teeth,  found  the  largest  pulp-stones  in  those  molar  teeth 
which  seemed  to  have  stood  a  severe  test  in  mastication  for  many 
years. 

Pathology." — Pulp  nodules  are  harder  than  normal  dentin, 
although  they  are  composed  of  the  same  material;  their  outward 
appearance  varies  from  a  minute  speck  hardly  discernible  by  the 
unaided  eye  to  those  which  nearly  fill  the  pulp  chamber;  they  are 
found  in  all  parts  of  the  chamber,  sometimes  in  the  midst  of  the 
pulp  tissue,  and  again  near  or  at  a  point  of  exposure,  and  often  at 
the  bifurcation  of  the  roots,  or  within  the  root-canal. 

The  pulp  tissue  itself  under  these  conditions  presents  a  normal 
appearance. 

Symptoms  and  Diagnosis. — Dr.  Black  says  that  in  studying  the 
pulps  of  teeth  of  known  history  he  has  been  unable  to  find  that 
those  with  pulp  nodules  have  given  any  peculiar  symptoms  or  have 
given  more  pain  than  those  without  these  bodies.*  It  is,  however, 
quite  possible  that  these  may  occur  of  such  size  near  the  con- 
junction of  the  coronal  and  root  portion  of  the  pulp,  or  in  the  root 
portion,  as  to  cause  degeneration  of  the  organ;  or  they  may  by 
their  volume  interfere  with  its  functions. 

The  few  symptoms,  if  any,  that  belong  distinctively  to  "pulp- 
stones"  make  the  diagnosis  comparatively  difficult.     The  expres- 

*  Dr.  R.  R.  Andrews  says  that  the  growths  are  liable  at  any  time  to  give 
pain,  or  cause  irritation  from  encroaching  on  nerve  fibers  of  the  pulp  by 
growth. 


NECROSIS.  195 

sions  of  pain  vary  from  a  slight  uneasiness  to  intense  suffering,  the 
teeth  being  especially  sensitive  to  heat  or  cold.  There  is  usually 
severe  pain,  often  intermittent,  with  soreness  on  pressure  in  the 
advanced  stages.  As  is  commonly  observed,  often  when  too  late 
for  a  more  speedy  and  satisfactory  treatment,  the  pulp  in  this  con- 
dition resists  the  usual  action  of  arsenic;  this,  if  recognized  early, 
may  lead  to  a  correct  diagnosis  and  improved  treatment. 

Treatment. — When  treatment  is  required,  the  tone  of  the  re- 
quest for  it  is  not  an  uncertain  one.  There  is  but  little  choice  in 
methods;  indeed,  there  is  only  one  treatment,  and  that  is  the  re- 
moval of  the  pulp,  with  the  hard  bodies  contained  within  its  cham- 
ber. The  methods  of  doing  this  may  vary.  It  may  be  accom- 
plished, probably,  by  the  slow  and  painful  one  of  repeated  applica- 
tions to  destroy  the  pulp,  but  the  pain  may  be  so  violent  as  to  pre- 
clude this  method.  Cocain,  or  carbolic  acid  injected  or  pumped 
into  the  pulp  cavity,  has  been  effectual,  also  the  employment  of 
general  anesthesia  by  nitrous  oxid  gas  or  ether. 


CHAPTER    XL. 

NECROSIS. 


Definition. — Death  of  a  tissue,  in  bulk. 

Etiology. — The  vitality  of  any  part  of  the  human  body  is  de- 
pendent upon  the  blood  as  a  circulating  medium.  If  the  general 
circulation  ceases,  death  of  the  whole  organism  takes  place.  If 
the  circulation  is  interrupted  in  part,  death  is  the  result,  but  it  is 
limited  to  the  part  involved.  As  the  term  necrosis  is  usually 
applied  to  death  of  the  bony  tissues,  so  the  term  gangrene  is 
applied  to  the  same  pathological  condition  of  the  soft  tissues;  for 
example,  death  of  the  dental  pulp  is  gangrene,  or  mortification. 
Death,  or  mortification,  of  the  pulp  occasionally  takes  place  with- 
out apparent  cause,  but  it  is  probably  due  in  such  cases  to  changes 
which  interfere  with  the  circulation  of  the  blood  as  above  described. 
There  are  cases  in  which  death  of  the  pulp  has  followed  typhoid 
fever  by  which  the  patient  had  been  brought  to  a  very  low  condi- 


196  THE    PRACTICE    OF    DENTAL   MEDICINE. 

tion,  in  which  it  may  be  supposed  that  the  circulation  within  the 
pulp  may  have  ceased,  and  that  this,  with  the  impoverished  condi- 
tion of  the  blood,  caused  death  of  the  part. 

Degenerative  changes,  the  action  of  medicines,  and  deposits  of 
secondary  dentin,  may  all  produce  the  results  mentioned,  but  in 
the  further  consideration  of  this  subject  we  shall  limit  our  discus- 
sion to  bony  tissue.  The  superficial  bones  are  most  frequently 
attacked,  as  the  tibia,  ulna,  lower  jaw,  etc.  The  long  bones  are 
affected  more  frequently  than  the  short,  and  the  short  rather  than 
the  flat,  while  in  caries  the  reverse  is  true.  Necrosis  occurs  fre- 
quently in  those  children  under  fifteen  years  of  age  who  are  the 
subjects  of  a  strumous  diathesis  or  who  have  a  syphilitic  taint; 
also  in  adults  who  have  been  subjected  to  long  courses  of  mercury. 
Local  irritation  in  many  forms  has  undoubtedly  a  causative  influ- 
ence; some  of  these  forms  of  irritation  are  the  result  of  contusions, 
fractures,  or  abscesses.  Frequently,  death  of  the  bone  results 
from  its  being  denuded  of  its  periosteum,  especially  if  this  be  con- 
siderable; it  is  also  true  that  if  the  bloodvessels  in  any  portion  of 
the  periosteum  and  in  the  medulla  of  the  bone  are  destroyed,  that 
portion  of  the  bone  tissue  which  fails  to  receive  its  necessary  blood- 
supply  becomes  necrotic. 

PhospJionis  has  in  former  years  been  quite  frequently  the  cause 
of  necrosis  of  the  lower  jaw.  In  several  cases  seen  at  the  clinics 
at  the  Pennsylvania  Hospital  the  necrosis  was  extensive  in  the 
lower  jaw,  while  the  upper  remained  unaffected.  This  phosphor- 
necrosis  is  somewhat  remarkable,  in  that  it  shows  such  a  decided 
preference  for  the  lower  jaw;  but  the  anatomy  of  the  jaws,  and  the 
manner  in  which  the  circulation  is  carried  on,  seem  to  offer  a  suffi- 
cient explanation.  The  lower  jaw  is  a  bone  of  considerable  length, 
being  bent  upon  itself.  The  blood  and  nerve  supply,  entering  at 
the  posterior  end,  passes  along  the  inferior  dental  canal  with  little 
inosculation  between  the  bloodvessels,  so  that  any  obstruction  to 
the  circulation  in  this  part  is  not  compensated  for,  by  reason  of  the 
lack  of  collateral  circulation. 

The  upper  jaw,  on  the  other  hand,  receives  its  blood  and  nerve 
supply  from  different  directions,  and  its  anatomical  structure  is 
different,  being  largely  composed  of  thin  plates  and  supplied  with 
periosteum  on  each  side.  If  the  circulation  on  one  side  is 
obstructed,  that  on  the  other  is  sufficient  to  supply  the  bone- 
nutriment. 


NECROSIS. 


197 


This  form  of  necrosis  was  first  noticed,  in  this  country,  by  Dr. 
James  R,  Wood,  who  gave  an  account  of  it  in  the  A^fzc  York 
Joii/rtwl  of  Medicine  for  i\fay,  1856,  with  the  history  of  a  case  in 
which  he  removed  the  entire  lower  jaw.  In  order  to  produce  this 
particular  form  of  necrosis  it  seems  to  be  necessary  that  the  vapor 
of  phosphorus  should  come  in  actual  contact  with  the  periosteum. 
It  has  also  been  said  that  only  those  persons  having  carious  teeth 
are  liable  to  this  affection.  However  this  may  be,  it  is  a  fact  that 
since  strict  regulations  have  been  carried  out  in  the  match-factories 
the  disease  has  been  of  less  frequent  occurrence.  These  regula- 
tions include  an  improvement  in  ventilation  and  rigid  enforcement 
of  the  rules  that  all  carious  teeth  of  the  employes  be  filled;  that 

Fig.  34. 


X-ray  illustration,  showing  an  imerupted  bicuspid. 

employes  practice  breathing  through  the  nose  instead  of  the 
mouth,  and  that  each  shall  wear  over  the  nose  a  sponge  saturated 
with  dilute  sulfuric  acid. 

When  impacted  fccfli  are  the  cause  of  necrosis,  the  X  rays  may 
be  used  to  locate  the  ofifending  tooth.  The  following  case  is  of 
interest  in  this  connection: 

The  patient,  Mrs.  L.  G.  S.,  having  suffered  from  dento-alveolar  abscess 
of  the  lower  first  molar  of  the  right  side,  this  tooth  was  removed;  but  the 
pain  and  discharge  continuing,  in  December  1896,  ether  was  administered 
and  an  attempt  was  made  to  remove  what  was  supposed  to  be  an  impacted 
tooth  at  the  site  of  the  second  bicuspid,  but  the  attempt  was  ineft'ectual. 
The  parts  being  less  painful,  the  condition  was  allowed  to  remain  until 
December  1897,  when  there  was  swelling  on  the  outside  of  the  face,  and  the 
patient  was  referred  to  the  writer. 

The  Roentgen  rays  showed  the  position  of  the  impacted  tooth.  (See 
Fig.  34-) 

An  incision  two  inches  long  was  made  at  the  lower  border  of  the 
body  of  the  jaw;   pus   escaped,   and   necrosed   bone  was   removed,   which 


198  THE   PRACTICE    OF   DENTAL   MEDICINE. 

revealed  the  end  of  the  impacted  tooth.  By  the  use  of  chisels  and  elevators 
the  tooth  was  finally  removed  through  the  mouth.  The  periosteum  was 
sewed  up  and  the  external  wound  closed  with  the  kangaroo-tendon  suture 
and  covered  with  iodoform  collodion.  In  ten  days  the  wound  had  healed, 
and  the  patient  is  making  a  good  recovery. 

The  following  case,  from  notes  kindly  supplied  by  Dr.  Henry 
O.  Marcy  of  Boston,  is  of  interest  as  showing  the  possible  injurious 
effect  of  the  use  of  hydrogen  peroxid: 

W.  A.  J.,  aged  fifty-seven,  merchant;  general  health  excellent. 
For  some  days  he  had  pain  about  the  right  lower  third  molar.  A 
large  amalgam  filling  had  been  placed  in  this  tooth  a  number  of 
years  previously,  but  it  had  never  given  trouble  until  the  present 
time.  Although  decay  was  not  present,  he  was  advised  to  consult 
his  dentist,  who  drilled  out  the  filling  with  much  difficulty,  on 
account  of  the  extreme  sensitiveness  of  the  parts. 

His  suffering  increased,  and  after  a  few  days  the  tooth  was 
extracted.  After  extraction  the  dentist  injected  hydrogen  peroxid 
into  the  socket;  it  was  immediately  followed  by  a  most  acute  lan- 
cinating pain  which  shot  around  the  jaw  quite  to  the  opposite  side. 
For  some  days  the  patient  was  confined  to  his  room,  and  the  pain 
was  controlled  only  by  large  opiates.  Tumefaction  of  the  entire 
lower  jaw  followed,  attended  with  great  difficulty  in  swallowing. 
This  was  accompanied  by  a  general  septic  fever  which  continued 
for  a  number  of  weeks,  during  which  period  a  fatal  issue  seemed 
imminent.  Suppuration  occurred  at  various  points  around  the 
entire  jaw,  opening  exteriorly  on  the  right  side.  Later,  under  an 
anesthetic,  I  removed  nearly  an  entire  set  of  sound  teeth,  which 
were  held  in  place  almost  only  by  their  attachment  to  the  inflamed 
soft  parts.  These  I  reflected  from  either  side,  and  with  bone- 
forceps  cut  away  the  necrosed  alveolar  process  quite  to  the  ramus 
of  the  jaw.  The  exterior  opening  on  the  right  side  was  found  to 
connect  with  one  of  the  pockets  about  the  alveolar  process,  and 
necrosis  of  a  part  of  the  outer  portion  of  the  ramus  of  the  jaw  was 
found  to  exist.     This  was  carefully  chiseled  away. 

Following  the  operation,  improvement  slowly  supervened,  but 
months  dragged  wearily  away,  and  quite  two  years  elapsed  before 
the  last  bit  of  necrosed  bone  was  exfoliated.  The  parts  would 
heal,  but  every  little  while  a  tender  place  made  its  appearance,  to 
mark  the  site  from  which  a  spicule  of  bone  would  escape.  The 
last  piece  to  be  detached  was  from  the  angle  of  the  jaw  posterior 
to  the  third  molar,  where  the  trouble  began.     Many  months  more 


NECROSIS.  199 

followed  before  artificial  teeth  could  be  fairly  well  tolerated,  and 
the  genius  and  skill  of  quite  a  number  of  our  best  dentists  have 
been  called  into  exercise  in  order  to  construct  plates  that  may  be 
made  serviceable.  The  success  in  this  direction,  however,  is  such 
as  to  prevent  any  disfigurement,  and  permits  of  easy  articulation 
without  impairment  of  speech,  and  mastication  of  carefully  pre- 
pared food.     The  general  health  is  restored  to  the  old-time  vigor. 

It  is  believed  that  the  injection  of  the  peroxid  penetrated  the 
inferior  dental  canal,  and,  instead  of  destroying  septic  elements, 
the  pressure  of  the  gas  generated  disseminated  them  through  the 
entire  length  of  the  canal,  and  caused  this  most  distressing  and 
dangerous  of  accidents  possible  to  the  lower  jaw.  It  is,  indeed, 
not  improbable  that  the  forceful  injection  of  pocketed  wounds  in 
any  part  of  the  body  with  peroxid  may  defeat  the  very  end  sought, 
and  endanger  the  contiguous  tissues  by  the  transplanting  of  un- 
destroyed  micro-organisms.  It  is  a  frequentl}-  observed  fact  that 
wounds  of  this  class,  faithfully  treated  in  this  way,  have  been  a 
source  of  vexation  and  disappointment  to  the  surgeon,  who  too 
often  charges  the  result  to  the  lack  of  the  antiseptic  property 
rather  than  to  its  probable  true  cause, — the  rapidly  generated 
gases,  which  from  pressure  disseminate  infection ;  and  it  is  for  this 
reason  that  the  above  clinical  case  is  inserted. 

Pathology. — The  manner  in  which  this  pathological  condition 
is  first  manifested  depends  much  upon  the  cause.  The  soft  parts 
over  the  seat  of  the  disease  are  always  affected,  soon  becoming 
tender  to  the  touch,  swollen,  and  discolored.  Following  this, 
pitting  under  pressure  indicates  the  infiltration  of  the  subcutaneous 
cellular  tissue.  The  local  conditions  are  often  sufficient  to  com- 
mand the  sympathy  of  the  entire  system,  and  general  symptoms  are 
accordingly  present.  We  are  not  surprised  at  this  when  we  take 
into  account  the  presence  of  pus,  often  deep-seated  and  located 
between  the  affected  bone  and  its  periosteum,  as  well  as  on  the 
outside  of  this  membrane,  and  in  the  connective  tissue  of  the 
muscles  and  aponeuroses,  which  it  often  extensively  permeates, 
detaching  the  one  from  the  other,  and  forming  pouches  from  which 
its  removal  is  often  dif^cult.  The  quantity  of  pus  is  often  large, 
being  derived  mostly  from  the  soft  tissue  surrounding  the  bone. 
The  first  stage  of  the  disease  being  over,  which  means  that  the 
excess  of  pus  has  been  discharged,  the  inflammatory  symptoms 
subside  in  a  measure,  although  the  soft  parts  are  still  swollen, 


200  THE    PRACTICE    OF    DENTAL    MEDICINE. 

tender,  and  painful.  The  periosteum  is  always  destroyed  to  a 
greater  or  less  extent  and  the  surface  of  the  bone  is  more  or  less 
rough,  presenting,  when  seen,  a  grayish-white  appearance.  This 
condition  may  be  determined  by  means  of  digital  exploration,  the 
use  of  the  probe,  or  actual  inspection  of  the  part.  As  a  general 
rule,  at  this  stage  of  the  disease  the  work  of  elimination  and  repair 
begins,  but  it  is  often  very  slowly  and  imperfectly  accomplished, 
depending  upon  the  recuperative  powers  of  the  system.  This  is 
quite  different  from  death  of  the  soft  tissues,  in  which  the  separa- 
tion of  the  sphacelus  is  easy  compared  with  that  of  bone,  which 
requires  weeks  and  perhaps  months  for  the  entire  separation  of  the 
dead  from  the  living  parts.  Necrosis  may  involve  only  the  outer 
layer  of  a  bone  or  it  may  include  its  entire  thickness  and  a  con- 
siderable measure  of  its  length.  If  only  a  small  portion  of  the 
outer  layer  is  thus  affected,  the  portion  detached  is  called  an 
exfoliation;  but  if  the  whole  body  of  the  bone  is  involved,  the  part 
thrown  off  is  called  the  sequestrum. 

In  the  lower  jaw,  the  outer  surface  of  bone  is  usually  first 
affected;  in  the  upper  jaw  it  may  attack  the  hard  palate,  or  the 
disease  may  include  an  indefinite  amount  of  either  jaw.  A  seques- 
trum is  formed  in  the  lower  jaw  only.  Often  many  of  the  teeth  are 
affected,  becoming  loose  and  discolored  until  their  removal  is 
necessary.  The  inflammation  which  precedes  and  accompanies 
necrosis,  involving  as  it  does  the  soft  parts  and  the  periosteum, 
may  extend  into  the  articulation  and  thus  seriously  affect  the 
motility  of  the  low^er  jaw.  Many  teeth  may  escape  destruction 
while  the  surrounding  alveolar  process  may  be  destroyed  to  a 
great  extent.  Dr.  G.  V.  Black*  reports  a  case  in  which  the  buccal 
plates  of  the  alveolar  process,  together  with  more  than  half  the 
septum  between  two  of  the  teeth,  were  destroyed  by  abscess,  yet 
the  teeth  were  found  in  very  good  condition  eight  years  after  the 
occurrence. 

Symptoms. — The  symptoms  giving  expression  to  death  of  bony 
tissue  are  often  much  the  same  as  those  which  indicate  acute  in- 
flammation. The  pain  is  often  excruciating,  suppuration  rapidly 
intervenes,  and  much  damage  is  done  even  in  a  few  days;  but  the 
progress  of  the  disease  is  not  always  so  swift  and  overwhelming; 
indeed,  it  may  be  quite  the  opposite,  with  very  little  pain,  and 
otherwise  pursuing  what  may  be  justly  termed  a  chronic  course. 

'^  "American  System  of  Dentistry,"  vol.  i.  p.  932,  fig.  488. 


NECROSIS.  201 

Following  these  earlier  symptoms,  those  which  indicate  the 
separation  of  the  dead  bone  and  the  formation  of  the  new  are  quite 
characteristic.  The  foreign  and  poisonous  material  which  is  con- 
stantly being  formed  gives  rise  to  an  accumulation  of  pus,  and 
ulcerations  may  be  seen,  surrounded  by  large  unhealthy  granula- 
tions, with  sinuses  leading  from  these  ulcers  down  to  the  dead 
bone.  There  is  a  discharge,  more  or  less  constant,  of  thin,  fetid 
matter,  or  of  thick,  white,  inodorous  pus.  This  is  accompanied 
by  more  or  less  swelling  and  some  induration,  pain  and  tenderness 
on  pressure,  and  wasting  of  the  soft  parts  adjacent  to  the  seat  of 
the  disease.  There  is  also  impaired  function,  according  to  the 
degree  to  which  the  joints  in  the  immediate  vicinity  are  affected. 

In  necrosis  of  bone,  the  disease  is  often  sufficiently  prolonged 
to  produce  a  marked  effect  upon  the  general  health,  as  indicated 
by  anemia  and  emaciation.  Hectic  fever  may  occur  when  the 
disease  is  extensive.  In  cases  of  phosphor-necrosis  the  symptoms 
assume  the  acute  form  which  we  have  just  described. 

It  should  be  noticed  in  this  connection  that  alveolar  abscess 
followed  by  necrosis  may  present  the  ordinary  symptoms  of 
alveolar  abscess,  which  after  treatment  of  the  abscess  by  incision  or 
by  extraction  of  the  tooth  may  disappear  altogether,  only  to  re- 
appear some  wrecks  or  months  later.  It  would  seem  in  such  cases 
as  though  the  cause  had  not  been  entirely  removed,  yet  it  would 
be  difficult  for  any  one  to  know  that  any  irritating  substance  had 
been  left  behind  which  should  ultimately  cause  necrosis.  It  would 
be  well,  therefore,  after  extracting  a  tooth  in  such  a  condition,  to 
gently  cleanse  the  socket  and  insert  a  light  antiseptic  dressing, 
changing  it  daily  until  this  is  found  to  be  unnecessary. 

Prognosis. — The  prognosis  is  uncertain,  depending  much  upon 
the  cause,  or  causes,  which  produce  the  disease.  In  a  general  way 
it  may  be  considered  favorable  when  the  disease  is  due  to  external 
or  local  causes;  when  it  is  confined  to  the  outer  portion  of  the  bone, 
and  the  bone  is  exfoliated;  also  when  the  disease  is  uncomplicated, 
and  of  small  extent;  and,  again,  it  is  favorable  when  the  patient  is 
young  and  in  good  health.  On  the  other  hand,  the  outcome  is 
more  doubtful  when  the  disease  is  extensive  and  has  serious  com- 
plications. In  extensive  necrosis  of  the  superior  maxillary  bones 
the  disease  may  extend  to  other  bones,  even  affecting  the  brain 
and  causing  death  thereby.  Its  progress  is  also  unfavorable  when 
it  extends  into  joints  of  large  size,  or  when  the  cause  is  a  constitu- 


202  '  THE    PRACTICE    OF    DENTAL   MEDICINE. 

tional  one,  as  scrofula  or  syphilis.  Finally,  if  the  patient  is  of 
advanced  age,  or  reduced  in  health  by  long  suffering  and  disease, 
we  anticipate  an  unfavorable  issue. 

Diagnosis. — As  a  general  thing,  necrosis  is  easily  distinguished 
by  the  denuded  state  and  whitish  appearance  of  the  affected  bone, 
by  the  existence  of  a  purulent  discharge,  and  by  an  extremely  fetid 
breath  when  it  occurs  within  the  oral  cavity.  The  use  of  the  probe 
is  essential,  and  may  tell  much  that  cannot  be  readily  ascertained 
upon  inspection,  or  exploration  with  the  finger.  Dead  bone  when 
struck  with  the  probe  produces  a  peculiar,  ringing  sound,  and  has 
a  very  different  feel  from  that  of  healthy  bone.  In  necrosis  the 
bone  transmits  a  dry,  rough  sensation  when  the  probe  is  passed 
over  it,  not  at  all  like  that  produced  by  the  smooth,  velvety  surface 
of  a  healthy  bone. 

It  is  sometimes  difficult  to  know  whether  a  separation  of  the 
dead  bone  from  the  living  has  been  effected.  In  such  a  case  two 
probes  may  be  used  to  advantage,  being  introduced  at  different 
points  and  moved  along  in  different  directions.  It  may  thus  be 
possible  to  ascertain  whether  the  separation  or  detachment  is  com- 
plete. The  following  comparison  between  necrosis  and  caries  is 
given  in  the  Dental  Cosmos  for  August  1893: 

Necrosis.  Caries. 

1.  Parts  affected  in  compact  tis-  i.  Most  common  in  cancellous 
sue.  Bloodvessels  are  better  sup-  tissue.  Here  is  room  for  dilatation 
ported  in  compact  bone,  and  so  less  and  exudation  without  causing  a 
liable  to  passive  congestion,  but  from  sudden  stasis  in  the  vessels. 

the  narrowness  of  the  canals  are 
quickly  strangulated  by  the  pressure 
of  the  exudation,  and  so  the  bone  is 
rapidly  anH  completely  deprived  of 
vitality. 

2.  Result  of  probing.  Probe  is  2.  Probe  is  felt  to  pass  through 
suddenly  arrested  by  striking  against  soft  inflamed  bone,  and  this  is  quite 
hard   bone,    without    giving   rise   to    sensitive. 

pain. 

3.  The  discharge  is  mostly  puru-  3.  Discharge  is  more  watery  or 
lent.  serous,  and  has  a  greater  amount  of 

lactic  acid. 

4.  Granulations  along  the  sinus  4.  Granulations  are  small  or  large, 
and  at  its  orifice  are  comparatively   pale  and  edematous. 

healthy,  often  fungous  and  florid. 


NECROSIS.  203 

5.  Cause.     The  more  acute,  local       5.     In  scrofula,  caries  is  most  corn- 
injury    or    constitutional,    as    acute    mon. 

specific  fever,  more  likely  is  inflam- 
mation to  end  in  necrosis. 

6.  In  syphilis  both  are  frequent. 

Treatment. — The  essentials  of  treatment  are  included  under 
three  heads:  first,  to  control  the  inflammation,  which  is  the  direct 
cause  of  the  trouble;  second,  a  waiting  treatment  which  consists  of 
antiseptic  and  acidulous  injections,  and  keeping  a  watch  over  the 
operations  of  nature  in  the  separation  of  the  old  bone  and  the 
formation  of  new;  third,  to  promote  the  removal  of  the  sequestrum. 

1.  The  first  of  these  objects,  namely,  the  control  of  the  inflam- 
mation, is  to  be  attained  by  the  proper  employment  of  antiphlo- 
gistic remedies,  such  as  aconite,  laxatives,  and  a  light  diet;  the 
lancet  may  often  be  used  locally  with  satisfaction,  and  opiates,  to 
allay  pain  and  induce  sleep,  may  serve  a  good  purpose.  As  soon 
as  fluctuation  is  perceived,  or  there  is  much  pain  and  tension,  or 
deep-seated  pus,  a  large  incision  should  be  made  at  one  or  more 
points.  This  incision  should  be  made  in  such  a  way  that  drainage 
may  be  facilitated  and  the  wound  kept  open. 

2.  In  the  second  place,  a  watch  is  to  be  kept  up  during  the 
sloughing  process  and  the  stage  of  reparation,  in  order  that  these 
processes  may  be  facilitated  to  the  greatest  degree.  Great  care 
must  be  exercised  that  the  disease  does  not  spread,  and  that  the 
patient  shall  not  become  exhausted  from  the  drainage  and  irrita- 
tion which  are  its  constant  accompaniments.  A  certain  amount  of 
inflammation  is  a  necessary  accompaniment  of  this  disease,  as  it 
aids  not  only  in  the  separation  of  the  dead  bone,  but  in  the  forma- 
tion of  the  new.  A  highly  nutritious  diet  is  required,  such  as 
animal  food,  milk  punch,  ale  or  porter;  also  the  use  of  iron  or 
quinin.  Aromatic  sulfuric  acid  should  be  siven  if  there  be 
hectic  fever  and  night-sweats;  also  outdoor  exercise  should  be 
taken  according  to  the  patient's  ability,  and,  in  fact,  every  means 
used  to  build  up  the  general  health. 

Cleanliness  must  be  maintained  by  the  use  of  antiseptic  washes, 
of  which  there  is  a  great  variety.  The  following  are  among  the 
best:  Solutions  of  carbolic  acid,  corrosive  sublimate,  and  peroxid 
of  hydrogen.  Much  has  been  said  regarding  the  use  of  acid 
solvents  as  an  aid  in  separating  the  sequestrum  from  the  living 
bone,  and  in  dissolving  the  sequestrum  itself.     In  using  such  acid 


204  THE    PRACTICE    OF   DENTAL   MEDICINE. 

injections,  if  the  solution  be  strong  enough  to  exercise  any  solvent 
action  upon  the  sequestrum,  it  will  also  act  upon  the  living  bone 
and  soft  tissues  injuriously;  therefore,  if  acid  solvents  be  employed 
at  all,  it  would  seem  to  be  better  practice  to  use  them  in  very  weak 
solutions,  with  a  view  to  their  cleansing  effects  rather  than  to  any 
solvent  action  which  they  might  be  expected  to  exert. 

After  the  inflammatory  stage  has  passed  it  would  be  well  to 
inquire  if  there  be  any  special  diathesis  which  should  be  combated. 
For  example,  if  the  patient  be  of  a  strumous  diathesis,  special 
remedies  need  to  be  employed,  for  it  must  be  evident  that  no  satis- 
factory progress  can  be  made  toward  a  cure  so  long  as  the  system 
is  handicapped  by  a  depraved  state  of  the  solids  and  fluids  of  the 
body. 

3.  The  third  object  to  be  fulfilled  is  to  get  rid  of  the  seques- 
trum, for  as  long  as  this  remains  it  acts  as  a  foreign  body  and 
irritant  which  must  necessarily  keep  up  inflammation  and  dis- 
charge. If  this  be  the  case  it  would  seem  that  the  sooner  it  is 
removed  the  better;  but  here  a  mistake  may  be  easily  made.  No 
removal  of  the  dead  bone  should  be  attempted  until  the  practi- 
tioner is  satisfied  that  it  has  become  completely  detached,  and 
the  new  bone  sufficiently  advanced  in  formation  to  enable  it  to 
retain  its  form  after  the  sequestrum  is  removed. 

The  removal  of  the  sequestrum  may  be  accomplished  either  by 
use  of  the  fingers,  aided  by  forceps,  or  by  the  forceps  alone.  In 
any  case  considerable  care  should  be  exercised,  in  handling  the 
forceps,  not  to  injure  the  surrounding  healthy  tissues.  If  the 
piece  be  very  large,  it  is  possible  that  an  incision  into  the  soft 
tissues  must  be  made,  or  the  sequestrum  itself  divided  with  a  saw 
or  cutting  pliers.  When  the  whole  of  the  lower  jaw  is  necrosed,  it 
is  nearly  always  necessary  to  divide  it  at  the  chin,  and  extract  each 
half  separately.  In  doing  this,  care  should  be  taken  to  remove  the 
bone  only,  the  periosteum  being  left  -in  situ,  for  the  formation  of  the 
new  bone. 

The  dead  bone  having  been  removed,  the  partially  organized 
granulations  on  the  inner  surface  of  the  new  bone  should  be 
scraped  away,  and  washed  out  by  free  injections  with  the  syringe. 
If  the  hemorrhage  be  profuse,  as  will  often  be  the  case  in  conse- 
quence of  the  great  vascularity  of  the  parts,  plug  the  cavity  with 
antiseptic  gauze  which  has  been  dipped  in  alum  or  tannic  acid. 

An   interesting   question   has   been    raised   in    regard   to   the 


NECROSIS.  205 

removal  of  teeth  with  alveolar  abscesses,  and  with  a  probable 
necrosis  of  the  surrounding  bone.  It  has  been  said  that  in  such 
a  case  attended  with  severe  inflammation  the  teeth  should  not  be 
removed  during  the  inflammatory  period;  that  the  wound  produced 
by  the  extraction  never  closes  while  there  is  necrotic  bone  beneath, 
and  that  infection  is  likely  to  spread  to  the  other  teeth.  It  is  a 
fact  that  in  such  cases  one  tooth  after  another  has  been  extracted 
and  that  the  disease  has  spread;  whether  b}'  reason  of  the  extrac- 
tion, or  whether  it  would  have  advanced  had  the  teeth  been  al- 
lowed to  remain,  is  a  question  which  has  caused  much  discussion. 

The  opinion  has  even  been  advocated  that  teeth  in  this  condi- 
tion if  allowed  to  remain  will  cause  the  spread  of  the  disease.  It 
would  seem  to  the  writer  that  in  the  condition  described  we  have 
carious  teeth  with  abscesses,  which  are  surrounded  by  necrosed 
bone;  there  is  acute  inflammation,  and  the  body  temperature  sym- 
pathizes with  it  in  proportion;  the  teeth  with  foul  pulps  and  ab- 
scessed roots  can  be  considered  as  nothing  less  than  foreign,  irri- 
tating bodies,  acting  as  the  cause  of  the  abscess  and  surrounding 
swelling,  and  cs  such  they  should  be  removed.  It  would  seem  that 
this  is  the  best  way  to  reduce  the  local  inflammation  and  the 
general  temperature. 

The  wound  may  possibly  be  kept  open  by  the  necrotic  tissues 
underlying  it,  but  after  the  removal  of  a  portion  of  the  infectious 
and  irritant  material,  vital  resistance  to  disease,  or  phagocytic 
action,  is  assisted  by  so  much,  and  there  is  now  a  greater  proba- 
bility of  the  disease  being  arrested  at  this  point. 

With  abscessed  teeth  in  the  jaw,  and  with  the  rapid  destruction 
that  is  going  on  during  acute  inflammation,  it  would  seem  far  more 
probable  that  infection  would  take  place  more  readily  at  points 
where  there  is  broken-down  tissue  than  it  would  if  the  source  of 
the  inflammation  were  removed  and  the  ends  of  the  vessels  sealed 
by  cauterization,  followed  by  antiseptic  washes. 

It  has  been  thought  best  by  some  to  treat  the  inflammation 
first,  and  remove  the  teeth  afterward.  What  better  treatment  of 
inflammation  can  there  be  than  the  immediate  removal  of  the 
offending  body,  and  the  release  of  pus  and  other  irritating  matter? 


206  THE    PRACTICE    OF    DENTAL    MEDICINE. 

CHAPTER    XLI. 

ANKYLOSIS  OF  THE  JAW. 

Definition. — Ankylosis  is  loss  of  motility  in  a  joint. 

Etiology. — 'Ankylosis  of  the  jaw"  is  a  condition  of  the  articu- 
lating surface  of  the  maxilla  which  hinders  its  normal  movement. 
An  inflammatory  condition  of  the  synovial  membrane  is  accom- 
panied by  an  effusion  which,  if  not  absorbed,  undergoes  certain 
changes  which  render  the  lower  jaw  more  or  less  immobile. 
This  condition  may  be  the  result  either  of  traumatism  or  of  certain 
pathologic  conditions.  The  common  traumatic  injuries  include 
blows,  contusions,  fractures,  and  dislocations.  Among  the  dis- 
eased conditions  are  tumors,  calcic  deposits  which  are  the  result  of 
a  uric  acid  diathesis,  mumps,  quinsy,  etc.  Difficult  eruption  of  the 
wisdom  teeth  may  cause  inflammation  and  swelling  which  hinder 
mobility  of  the  mandible.  The  after-effects  of  surgical  operations 
about  these  parts,  such  as  cicatrices  and  adhesions,  tend  to  contrac- 
tion and  fixation  of  the  jaws.  When  tuberculosis  affects  the  bones 
and  the  synovial  surfaces  of  joints,  the  destruction  of  these  sur- 
faces is  followed  by  granulation  tissue,  connective  tissue,  and  bone, 
which  interferes  with  the  normal  movement  of  the  lower  jaw, 
although  bony  ankylosis  is  not  usually  complete  until  a  year  or 
two  after  the  acute  process  has  taken  place. 

Recent  experiments  upon  animals  throw  some  doubt  upon  the 
idea  that  if  the  jaws  are  maintained  in  one  position  for  a  long  time 
ankylosis  results.  A  healthy  joint  which  has  been  placed  in  a 
splint  for  six  months  may  be  found  mobile.  From  these  experi- 
ments and  other  studies  in  this  direction  it  is  known  that  ankylosis 
is  a  result  of  some  inflammatory  condition. 

Treatment. — Inflammation,  when  it  is  present,  must  be  sub- 
dued, first,  by  removing  the  cause.  If  an  erupting  third  molar  is 
the  cause  of  the  trouble,  and  there  is  much  swelling  with  inability 
to  open  the  mouth,  treatment  must  be  instituted,  and  as  soon  as  the 
mouth  can  be  sufficiently  opened,  the  tissue  about  the  offending 
tooth  should  be  properly  treated,  or  the  tooth  itself  removed.  If 
the  inflammation  consequent  upon  the  original  irritant  has  sub- 
sided, and  we  have  to  deal  with  cicatrices  or  adhesions  of  long 
standing,  the  treatment  consists  in  passive  motion  of  the  jaw, 
brought  about  in  some  way  which  the  operator  shall  devise. 


EMPYEMA    OF   THE    MAXILLARY    SINUS.  207 


DISEASES   AFFECTING  THE   ADNEXA   OF   THE  MOUTH, 


CHAPTER    XLII. 

EMPYEMA  AND  OTHER  PATHOLOGICAL  CONDITIONS  OF 
THE  MAXILLARY  SINUS. 

Definition. — Empyema  of  the  maxillary  sinus  is  a  collection  of 
pus  in  this  cavity. 

Etiology. — The  maxillary  sinus  may  occasionally  share  in  the 
acute  inflammation  which  accompanies  a  "cold  in  the  head;" 
inflammation  of  the  sinus,  however,  more  commonly  occurs  by 
reason  of  the  extension  of  disease  from  other  parts,  or  as  the  result 
of  a  physical  injury  to  its  walls.  Recent  anatomical  studies*  have 
demonstrated  the  possibility  of  empyema  of  the  frontal  sinus  and 
disease  of  the  ethmoidal  cells  extending  by  way  of  the  infundibulum 
to  the  maxillary  sinus,  thus  accounting  for  many  obstinate  cases 
of  antral  disease  which  have  resisted  treatment. 

The  roots  of  the  first  and  second  molars  frequently  extend 
nearly  through  the  floor  of  the  antrum,  thereby  making  it  possible 
for  the  pus  from  an  alveolar  abscess  around  such  roots  to  find  its 
way  into  the  antral  chamber,  irritating  its  lining  membrane  and 
setting  up  an  inflammation;  or,  on  the  other  hand,  antral  disease 
may  so  interfere  with  the  nutrition  of  the  above-named  teeth  that 
it  results  in  death  of  their  pulps  followed  by  alveolar  abscess,  which 
in  turn  discharges  into  the  antrum.  Thus  antral  disease  may  be 
due  to  alveolar  abscess,  or  alveolar  abscess  may  be  due  to  antral 
disease. 

As  to  the  relative  frequency  with  which  empyema  of  the  antrum 
is  due  to  nasal  or  dental  diseases,  opinions  are  divided.  It  has 
been  said  that  dentists  claim  that  this  disease  is  more  frequently 
due  to  diseased  teeth,  while  rhinologists  insist  that  nasal  disease 
is  more  frequently  a  cause.  Dr.  M,  R.  Brown,  of  Chicago,  attrib- 
utes a  large  number  of  cases  to  "catching  cold;"  the  mucosa  of 
the  maxillary  sinus  becoming  inflamed,  and  the  congestion  serving 

*  Dr.  M.  H.  Cryer,  in  the  Dental  Cosmos  for  January  1896;  Dr.  T.  Fille- 
brown,  ibid.,  November  1896. 


2o8  THE    PRACTICE    OF    DENTAL    MEDICINE. 

to  close  the  natural  opening  to  the  nose,  secretions  are  retained 
and  degenerate  into  pus.  Dr.  Brown  cites  the  following  case  from 
his  own  practice: 

Mr.  X.  after  exposure  on  a  cold  and  windy  day  was  confined  to  the 
house  with  a  severe  pain  in  the  left  cheek  simulating  neuralgia.  In  a  few 
days  a  discharge  of  fetid  pus  set  in  from  the  nasal  cavity  of  the  affected 
side.  This  was  followed  by  nasal  obstruction,  which  was  not  present  at  the 
beginning  of  the  case.  The  inference  to  be  drawn  is  that  the  inflammation 
of  the  antrum  was  primary,  and  existed  independently  of  any  nasal  trouble. 

Intra-nasal  tumors  may  act  as  a  cause  of  empyema  of  the 
antrum  by  occluding  the  opening  into  the  nose.  The  frequency 
with  which  tumors  are  found  in  the  nasal  cavities  is  well  shown  by 
P.  Heymann  of  Berlin,  who  examined  five  hundred  specimens  of 
antra  and  found  thirty-one  tumors.  Only  when  the  tumors  are 
very  large  and  empyemic  are  they  discovered  during  life.  Other 
causes  may  be  found  in  traumatism,  dentigerous  cysts,  polypoid 
degenerations  within  the  antral  cavity,  and  influenza. 

Dr.  M.  H.  Fletcher,  in  a  paper  read  before  the  section  of  Dental 
and  Oral  Surgery  of  the  American  Medical  Association  in  June, 
1893,  gives  reasons  for  believing  that  the  majority  of  antral  cases 
are  due  to  intra-nasal  disorders.  The  substance  of  the  testimony 
is  as  follows:  There  is  no  intimate  nervous  connection  between 
the  teeth  and  the  antrum,  so  there  could  be  no  disease  by  reason  of 
reflex  action  from  one  to  tlie  other. 

Out  of  two  hundred  examinations,  Dr.  Fletcher  found  fifty- 
seven  ulcerated  teeth,  only  four  of  which  had  perforated  the 
antrum;  the  other  fifty-three  had  discharged  through  the  alveolus 
into  the  mouth.  From  two  hundred  and  twenty-four  cases  of 
pulpless  teeth  in  superior  molars  in  his  own  practice,  Dr.  Fletcher 
knew  of  only  one  which  penetrated  the  antrum;  he  has,  however, 
treated  a  case  in  which  the  teeth  were  made  pulpless,  and  some  of 
them  lost  in  consequence  of  disease  of  the  antrum,  and  he  believes 
that  this  condition  is  of  more  frequent  occurrence  than  the  reverse. 

On  the  other  hand.  Dr.  I.  P.  Wilson,  in  a  paper  read  before  the 
Dental  Congress  at  Chicago,  1893,  claims  that  antral  disease  is 
frequently  of  dental  origin.  He  thinks  that  pus  from  a  pulpless 
tooth  may  find  its  way  readily  through  the  thin  layer  of  bone 
which  forms  the  floor  of  the  antral  cavity,  and  that  it  does  do  so 
frequently,  instead  of  perforating  the  alveolar  plate  and  going 
into  the  mouth.     He  gives  no  record  of  a  large  number  of  cases 


EMPYEMA    OF   THE    MAXILLARY    SINUS.  209 

or  data  to  support  his  conclusions,  but  cites  a  case  illustrating 
the  subject  of  which  the  substance  is  as  follows: 

Mrs.  C.  complained  of  a  diseased  condition  of  her  teeth,  with 
symptoms  of  a  dead,  heavy  pain  in  her  cheek-bone  and  "under  the 
bridge  of  her  nose,"  also  in  the  frontal  region.  Her  eyes  had  a 
languid  appearance,  and  were  continually  discharging  a  water- 
like substance.  She  complained  also  of  "nasal  catarrh,"  with 
offensive  breath,  nervousness,  no  appetite,  loss  of  the  sense  of 
smell,  and  resonance  of  the  voice.  Examination  showed  that  the 
upper  second  bicuspid  and  first  molar  had  been  filled  years  before. 
Soon  after  they  had  been  filled,  one  or  both  ached;  this  condition 
being  followed  by  a  swollen  face,  since  which  time  they  had  given 
no  trouble.  Both  teeth  were  found  to  contain  putrescent  pulps, 
with  no  visible  means  of  escape  for  the  foul  matter  and  gases 
that  were  continually  forming. 

The  teeth  were  both  extracted  and  an  opening  into  the  antrum 
was  found.  Injections  of  warm  water  into  the  antral  cavity  were 
made,  and  a  large  amount  of  pus  and  abnormal  products  removed. 
This  was  followed  by  cleansing  treatment  with  sprays  to  the  nose, 
and  in  a  year's  time  the  patient  had  fully  recovered. 

Pathology  and  Symptoms. — A  prominent  symptom  is  a  dis- 
charge from  one  nostril,  but  there  is  always  the  possibility  of  both 
antra  being  affected  and  a  consequent  discharge  from  both  nostrils. 
Further  inquiry  should  lead  to  an  inspection  of  .the  teeth,  and  to 
an  intra-nasal  examination. 

Dull  pain  in  the  antral  region,  heat,  and  slight  swelling  of  the 
external  soft  parts  are  seen  only  in  cases  of  obstruction  of  the 
orifice  to  the  antrum. 

If  the  disease  is  due  to  the  teeth,  in  a  large  proportion  of  cases 
we  shall  find  alveolar  abscess  or  its  history. 

In  the  nose,  a  swelling  obstructs  the  passage  more  or  less,  and 
the  surface  of  the  middle  and  inferior  turbinated  bodies  are  par- 
tially covered  with  a  thick,  creamy,  yellow  pus.  The  act  of  leaning 
forward  and  inclining  the  head  downward  increases  the  discharge 
of  pus,  as  described  by  Boyer  of  Brussels. 

In  some  cases,  especially  if  the  passage  to  the  nose  be  closed, 
the  face  on  the  affected  side  is  swollen,  there  is  distension,  and  a 
sensation  of  fullness  and  pain  referable  to  the  cheek. 

In  many  cases  the  disease  is  insidious,  and  active  symptoms  are 
absent,  especially  in  the  early  stages.     The  patient  suffers  in  such 

15 


2IO  THE   PRACTICE    OF    DENTAL   MEDICINE. 

cases  less  from  pain  than  from  the  inconvenience  resulting  from 
the  discharge,  and  from  the  uncomfortable  feeling  of  obstruction 
in  the  nose. 

Diagnosis. — Authorities  differ  widely  as  to  the  ease  with  which 
diseases  of  the  maxillary  sinus  may  be  diagnosticated.  The  pres- 
ence of  pus  in  the  antrum,  as  before  indicated,  may  excite  no 
symptoms  beyond  a  purulent  or  muco-purulent  nasal  secretion 
which  may  be  taken  by  the  patient  for  that  of  a  common  cold;  and 
therefore  it  has  been  suggested  that  antral  diseases  have  been  more 
frequent  than  past  clinical  observations  would  lead  us  to  believe. 
These  outward  signs  are  the  more  important  for  the  reason  that 
little  dependence  can  be  placed  upon  the  subjective  symptoms. 

As  a  constant  symptom  we  may  place  reliance  on  the  purulent 
discharge,  usually  from  one  nostril.  Dr.  M.  R.  Brown  of  Chicago 
shows  a  record  of  bilateral  discharge  in  seventeen  per  cent,  of  his 
cases.  The  character  of  the  discharge  varies  from  a  purulent, 
creamy  consistence  to  a  thickened  caseous  degeneration,  according 
to  its  chronicity.  The  odor  varies  also,  sometimes  from  a  mere 
unpleasantness  to  one  which  is  very  offensive.  If  the  pus  is  wiped 
away  from  the  middle  meatus  and  inferior  turbinal,  it  can  often  be 
made  to  reappear  immediately  by  holding  the  head  downward. 
This  procedure  may  form  a  distinctive  feature  between  causes 
acting  in  the  maxillary  sinus  and  those  originating  in  the  other 
accessory  cavities  leading  to  the  nose,  for  all  of  the  above-men- 
tioned symptoms  may  occur  in  disease  of  the  frontal  and  anterior 
ethmoidal  sinuses. 

As  a  means  of  diagnosis,  resort  may  be  had  to  the  following 
methods  of  procedure,  as  suggested  by  Dr.  Brown  of  Chicago: 
Transillumination.    Sounding.    Irrigating.    Exploratory  puncture. 

The  method  of  transillumination  is  of  use  as  a  means  of  diagno- 
sis, but  it  is  not  always  a  conclusive  test.  It  is  easily  applied  and 
is  becoming  popular  as  a  preliminary  step  to  the  more  conclusive 
method, — exploratory  puncture. 

Dr.  Holger  Mygind  of  Copenhagen  has  recently  laid  stress 
upon  the  importance  of  examining  the  antrum  in  the  healthy  indi- 
vidual and  in  a  large  number  of  cases.  He  gives  a  list  of  two 
hundred  persons,  eighty-eight  males  and  one  hundred  and  twenty- 
two  females,  of  ages  varying  from  two  to  seventy-six  years,  ex- 
amined by  a  lamp  of  eight  volts  burning  with  a  perfectly  white 
light.     Dr.  Mygind  says  that  in  order  to  have  satisfactory  results 


EMPYEMA    OF   THE   MAXILLARY    SINUS.  211 

there  must  be  a  totally  dark  room.  It  is  necessary  also  to  observe 
whether  the  patient  is  wearing  a  plate  containing  artificial  teeth. 

Dr.  Mygind  observes  that  very  different  results  are  obtained  in 
the  examination  of  different  individuals,  and  makes  the  following 
observations:  In  thin,  slightly  built  individuals  the  illuminations 
are  very  intense,  and  the  pupils  of  the  eyes  exhibit  a  deep  red 
color  differing  from  that  of  the  face.  In  strongly  built  men  of 
■dark  complexion  the  transillumination  was  less  pronounced  and  the 
pupils  remained  dark.  In  many  persons  the  transillumination  of 
the  pupils  was  unequal.  This  is  important  and  shows  the  necessity 
of  a  thorough  knowledge  of  the  appearances  of  transillumination  of 
the  face  in  the  healthy  individual.  The  shape  of  the  antral  cavity 
may  influence  the  amount  of  light  which  would  reach  the  eye;  for 
instance,  if  this  cavity  be  comparatively  wide,  it  is  obvious  that 
more  light  would  pass  than  if  the  antral  cavity  were  narrow  and 
high.  The  consistence  and  extent  of  the  fatty  layer  of  the  orbits 
probably  influence  the  amount  of  transillumination,  therefore  "the 
above-mentioned  circumstances  must  be  taken  into  consideration" 
m  making  a  diagnosis,  for  non-illumination  may  be  caused,  not  by 
pus  only,  but  by  other  conditions  which  are  not  necessarily  patho- 
logical. 

Cases  are  cited  by  Dr.  Brown,  showing  that  with  decided  indi- 
cations of  the  presence  of  pus,  upon  opening  the  antrum  no  pus 
was  found;  and  on  the  other  hand,  when  pus  was  found  and  re- 
moved by  thorough  irrigation,  the  electric  light  showed  the  same 
signs  of  pus  as  before.  Dr.  Brown  does  well  in  calling  attention 
to  the  fact  that  transillumination,  while  not  conclusive  as  to  the 
presence  of  pus,  does  show  an  abnormal  condition  of  thickened 
and  infiltrated  mucosa  of  the  antrum  and  accessory  cavities,  and 
the  method  thus  becomes  valuable  in  noting  the  progress  of  the 
case. 

The  method  of  sounding  is  pronounced  so  difficult  and  unsatis- 
factory that  it  is  dismissed  without  further  remark. 

Dr.  Brown  describes  in  detail  his  method  of  using  peroxid  of 
■hydrogen  as  a  diagnostic  means : 

Having  thoroughly  cleansed  the  nose  and  cocained  the  nasal  mucosa 
(especially  the  middle  and  inferior  turbinals),  a  small  hypodermic  syringe 
having  a  long  silver  cannula,  bent  within  a  quarter  of  an  inch  from  the  distal 
end  to  nearly  a  right  angle,  is  passed  into  the  semilunar  hiatus,  and  a  solu- 
tion of  peroxid  of  hydrogen  (one  part  to  tv^^elve  parts  of  water)  is  injected 
into  the  antrum.     If  pus  is  present  it  is  displaced,  and  fills  the  nose  with  a 


212  THE    PRACTICE    OF    DENTAL    MEDICINE. 

white  foam.  That  the  solution  has  entered  the  sinus  will  be  made  evident 
by  the  patient  complaining  of  slight  pain  at  the  roots  of  the  teeth  and  a 
sense  of  fullness  of  the  cheek.  The  method  is  free  from  danger  and  fairly 
easy  of  application,  and  is  to  be  commended. 

There  are  various  methods  of  entering  the  antrum  for  purposes 
of  exploration  and  treatment.  Each  of  these  methods  has  its 
advocates,  but  the  method  to  be  employed  in  many  cases  is  sug- 
gested by  the  conditions  of  the  case;  sometimes  one  method  is  best, 
and  sometimes  another.  Of  the  following  a  selection  may  be 
made  which  seems  best  suited  to  the  conditions  which  present:  A 
perforation  may  be  made  through  the  outer  wall  of  the  nose  at 
the  site  of  the  inferior  meatus,  by  means  of  a  suitable  trocar, 
aspirating  syringe,  or  trephine.  Or,  entrance  into  the  antrum  may 
be  afforded  through  the  canine  fossa,  or  through  the  alveolus  of 
an  extracted  tooth,  that  of  the  first  molar  being  preferred.  By 
this  means  the  presence  or  absence  of  pus  may  be  determined,  un- 
less there  are  septa  within  the  cavity  which  divide  it  into  separate 
compartments. 

Treatment. — The  principles  of  treatment  of  antral  diseases  are 
few  and  simple.  These  consist  mainly  in  affording  a  passage  for 
the  escape  of  abnormal  products  from  the  antral  cavity,  followed 
by  irrigation  and  the  application  of  certain  medicinal  agents  to  the 
lining  membrane. 

If  an  opening  into  the  antrum  is  to  be  made,  the  circumstances 
may  be  such  that  there  can  be  no  question  as  to  its  location.  In 
many  cases,  however,  there  is  a  division  of  opinion  in  this  respect, 
and  it  must  be  said  that  there  are  advantages  in  some  methods  that 
do  not  obtain  in  others.  With  a  clear  idea  of  the  objects  which  are 
to  be  attained,  the  method  possessing  the  greatest  number  of  ad- 
vantages should  be  employed.  In  opening  into  the  antrum,  it  is 
important  (as  in  opening  an  abscess)  to  have  the  opening  at  the 
most  dependent  part  in  order  to  facilitate  drainage.  If  there  are 
numerous  septa  of  bone  dividing  the  antral  chamber,  it  will  be 
more  difficult  to  secure  perfect  drainage,  and  this  would  be  an 
added  reason  for  making  a  large  opening  through  the  canine  fossa, 
in  order  that  the  cavity  may  not  only  be  thoroughly  explored,  but 
accessible  to  treatment  in  all  its  parts.  If  there  is  a  useless  molar 
or  stump  at  the  site  where  an  opening  might  be  made,  it  is  un- 
doubtedly good  practice  to  remove  this  and  enlarge  the  opening. 
It  is  the  experience  of  many  that  pus  does  not  always  make  its 


EMPYEMA    OF    THE    MAXILLARY    SINUS.  213 

appearance  immediately  upon  opening  the  antrum,  but  upon  the 
following  day. 

When  a  suitable  opening  has  been  obtained,  the  cavity  should 
be  thoroughly  irrigated  with  some  antiseptic  solution,  as  that  made 
with  Seller's  tablets,  Dobell's  solution,  a  saturated  solution  of 
boric  acid,  peroxid  of  hydrogen,  or  carbolic  acid.  This  should 
be  done  twice  at  least  each  day,  the  opening  being  kept  free  by 
means  of  a  drainage-tube. 

In  cases  of  long  standing,  and  in  which  there  seems  to  be  little 
or  no  progress,  an  opening  through  the  canine  fossa  is  justifiable. 
Through  this  opening,  sufficiently  enlarged,  one  may  explore  with 
the  finger  and  the  electric  light,  and  if  the  mucosa  is  very  much 
thickened,  or  there  is  much  caseous  pus,  the  parts  should  be  thor- 
oughly curetted,  washed  out,  and  packed  with  antiseptic  gauze. 
The  patient  may  then  be  dismissed  till  the  following  day,  when  the 
gauze  is  to  be  removed  and  the  cavity  irrigated,  following  this 
treatment  by  insufiflation  of  europhen,  aristol,  or  iodol.  This 
should  be  repeated  every  second  day. 

While  local  treatment  is  usually  imperative,  it  is  necessary  to 
look  after  the  general  condition  of  the  patient,  for  it  may  be  re- 
sponsible in  a  large  measure  for  the  production  and  continuance 
of  the  local  trouble.  Therefore  the  general  health  should  be 
brought  up  k)  the  highest  point. 

Other  Pathological  Conditions  of  the  Antrum. — While 
the  antral  cavity  may  be  the  subject  of  other  pathological  condi- 
tions, they  are  not  often  manifest  until  degeneration  and  pus- 
formation  has  occurred. 

Syphilitic  ulceration  may  extend  into  the  maxillary  sinus, 
necrosis  of  its  walls  may  take  place,  and  various  tumors  may 
occupy  this  cavity, — requiring  bold  therapeutic  treatment  in  the 
case  of  syphilis,  and  more  extensive  surgical  interference  than  that 
indicated  in  the  ordinary  forms  of  antral  disease;  and  the  reader  is 
therefore  referred  to  works  on  suro-erv. 


214  THE    PRACTICE    OF    DENTAL   MEDICINE. 

CHAPTER    XLIII. 

HYPERTROPHY  OF  THE  FAUCIAL  TONSILS. 

This  condition  of  the  tonsils  is  generally  seen  in  children;  it 
may  be  found  in  others  up  to  the  age  of  forty  years,  but  after  this 
age  it  is  of  rare  occurrence.  A  scrofulous  diathesis  plays  an  im- 
portant part  in  the  causation  of  this  condition;  while  certain  dis- 
eases also,  such  as  scarlatina  and  diphtheria,  may  be  classed  as 
having  a  causative  action.  The  dentist  is  often  asked  for  the  cause 
of  fetor  of  breath;  he  should  then  be  able  to  say  whether  it  arises 
from  the  teeth,  and  if  not,  he  should  have  a  sufficient  knowledge  of 
the  normal  and  abnormal  condition  of  the  tonsils  to  be  able  to 
advise  patients  as  to  an  examination  of  these  organs  as  the  prob- 
able cause  of  the  trouble. 

In  very  many  cases  of  enlarged  tonsils,  irregularities  of  the 
teeth  and  adenoid  growths  are  associated.*  Extreme  hypertrophy 
of  the  tonsils  should  be  especially  noted  before  administering  an 
anesthetic. 

Enlarged  tonsils  are  also  an  indication  of  a  uric  acid  diathesis, 
and  therefore  a  factor  in  phagedenic  pericementitis. 

Symptoms. — The  breathing  of  the  patient  is  usually  through  the 
mouth,  and  is  noticeable  by  reason  of  its  noisy  character.  Some- 
times the  gland  is  so  enlarged  as  to  be  seen  from  the  outside,  and 
it  certainly  may  be  felt  by  digital  examination.  The  obstruction 
causes  snoring,  disturbed  sleep,  and  a  muffled  tone  of  voice  which 
is  characteristic. 

Treatment. — If  the  tonsils  are  large  enough  to  obstruct  the 
breathing  in  any  way,  or  to  interfere  with  the  health  or  comfort 
of  the  patient,  they  should  receive  treatment  at  once.  The  fact 
that  they  tend  to  disappear  after  the  age  of  forty  should  not  weigh 
against  operation  or  treatment,  for  much  damage  may  be  done  to 
the  general  health  before  this  age  is  reached. 

Enlarged  tonsils  are  always  liable  to  acute  attacks;  and,  cer- 
tainly, during  the  treatment  of  an  acute  disease  such  as  scarlatina 

*  Dentists  should  bear  this  fact  in  mind,  for  upon  them,  in  great 
measure,  rests  the  responsibility  of  informing  parents  of  the  probable 
existence  of  adenoid  growths. 


HYPERTROPHY    OF   ADENOID    TISSUE,    ETC.  215 

or  diphtheria,  their  presence  must  be  considered  as  an  unfavorable 
complication  and  as  a  decided  interference  with  proper  treatment. 
This  condition  must  also  be  reckoned  as  an  undesirable  factor  to 
be  taken  into  account  when  one  is  about  to  administer  an  anes- 
thetic; moreover,  the  crypts  of  the  tonsil  often  contain  septic 
matter,  affecting  the  breath  and  inviting  disease. 

We  have  a  choice  of  several  methods  of  treatment.  Those 
cases  in  which  ablation  is  not  desirable  may  be  treated  by  means 
of  the  galvano-cautery  knife, — a  safe  and  sure  remedy. 

As  a  substitute  for  the  cautery,  trichloracetic  acid  may  be  used 
with  good  effect,  applied  by  means  of  a  finely  pointed  glass  tube. 

The  cold  wire  snare  should  be  used  in  preference  to  the  tonsil- 
lotome,  especially  in  adults,  in  whom  there  is  the  possibility  of  a 
serious  hemorrhage,  for  in  the  use  of  the  snare  the  loss  of  blood  is 
very  slight. 


CHAPTER    XLIV. 

HYPERTROPHY  OF  ADENOID  TISSUE  IN  THE  POST-NASAL 

SPACE. 

Synonyms. — Adenoid  growths;  Adenoid  vegetations;  Aden- 
omata of  the  pharynx;  Hypertrophy  of  the  pharyngeal,  or 
Luschka's,  tonsil;  H3'-pertrophy  of  the  third  tonsil;  Lymphoid 
growths  in  the  vault  of  the  pharynx. 

Definition. — By  adenoid  overgrowths  is  meant  the  enlargement 
of  lympliatic  glands,  situated  in  the  vault  of  the  pharynx. 

History. — Post-nasal  growths  have  within  the  last  half-dozen 
years  awakened  great  and  increasing  interest  in  the  dental  profes- 
sion. The  comparatively  recent  date  1868  marks  the  first  ac- 
count of  the  true  clinical  and  therapeutic  importance  of  these 
structures,  by  Meyer  of  Copenhagen.  Other  observers  had,  how- 
ever, as  early  as  i860,  referred  indifferently  to  growths  in  the  naso- 
pharynx. At  the  International  Medical  Congress  held  in  London 
in  1881  the  subject  received  a  detailed  discussion  by  some  of  the 
leading  authorities  on  the  nose  and  throat,  since  which  time  the 
profession  generally  have  been  more  or  less  familiar  with  the  dis- 
ease. 


2l6  THE    PRACTICE    OF    DENTAL   MEDICINE. 

Etiology. — Adenoid  growths  occur  most  frequently  in  children 
and  in  young- adults.  They  are  rarely  seen  after  the  age  of  thirty. 
The  author,  however,  has  removed  with  benefit  from  a  patient  aged 
fifty-five  5^ears  several  stalactite  adenoid  growths  averaging  half  an 
inch  in  diameter. 

Authorities  dififer  as  to  the  direct  causes  of  this  condition. 
Heredity,  of  course,  is  a  possible  factor,  though  there  are  those 
who  deny  its  importance.  Dr.  Harrison  Allen  states  that  the 
growths  are  frequently  hereditary,  since  the  pre-existent  states  on 
which  they  depend  are  transmissible. 

Climate,  according  to  some  authorities,  may  have  an  influence 
in  the  causation  of  this  disease,  since  it  is  found  most  frequently 
in  damp  and  cold  climates.  Yet,  at  the  Australian  Medical  Con- 
gress at  Sydney  in  1892,  Dr.  Hamilton  said:  "A  disease  so  exten- 
sively prevalent  in  Europe  and  Australia  must  owe  its  cause 
[origin]  to  other  than  climatic  causes."  He  believed  it  to  be  due 
rather  to  a  depressed  condition  of  the  general  health. 

Mackenzie  and  Loewenberg  have  observed  that  adenoid 
growths  are  common  among  cleft-palate  patients.  It  is  interesting 
to  note,  in  this  connection,  the  immunity  of  the  negro  from  cleft 
palate.  In  order  to  obtain  full  information  on  this  point,  the 
author  sent  circular  letters  to  many  of  the  prominent  surgeons  of 
the  South  and  also  to  prominent  specialists  in  this  country  and  in 
Europe,  asking  the  following  questions : 

1.  Have  you  ever  seen  a  case  of  congenital  cleft  palate  or  hare- 
lip in  the  negro? 

2.  Do  you  ever  see  enlarged  faucial  tonsils  in  the  negro? 

3.  Have  you  ever  known  of  a  case  of  adenoid  overgTowth  in 
the  vault  of  the  pharynx  of  the  negro? 

To  sum  up  the  answers  to  these  questions,  it  may  be  briefly  said 
that  several  surgeons  of  large  practice  have  never  seen  hare-lip, 
cleft  palate,  etc.  in  the  pure-blooded  negro;  and  that  while  other 
surgeons  have  seen  such  cases  they  believe  them  to  be  very  rare  as 
compared  with  similar  cases  in  the  white  race.  Occasional  in- 
stances are  found  among  mulattoes,  but  it  is  doubtful  if  they  are 
ever  found  in  the  pure-blooded  negro.  It  should,  however,  be 
said  that  adenoid  growths  may  pass  unnoticed  in  the  negro  from 
the  fact  that  his  nasal  passages  are  so  short  and  wide  that  the  tissue 
might  attain  a  considerable  growth  without  producing  the  charac- 
teristic symptoms  of  nasal  obstruction  and  mouth-breathing. 


HYPERTROPHY    OF   ADENOID    TISSUE,    ETC.  21/ 

A  scrofulous  diathesis  should  be  mentioned  as  a  possible  pre- 
disposing cause,  though  not  a  common  one.  Taking  cold  has 
been  thought  to  be  an  exciting  cause,  but  this  is  frequently  a 
s3'mptom.  Sajous  speaks  of  "an  oft-repeated  inflammatory  pro- 
cess" as  an  active  cause,  owing  to  the  weak  recuperative  powers 
of  the  lymphatic  glandular  tissue. 

Nasal  catarrh  has  also  been  given  as  a  cause  of  this  disease. 
Lenox  Browne  says :  "Certainly  purulent  and  muco-purulent  nasal 
catarrh  in  children,  the  irritant  nature  of  which  is  shown  by  eczema 
of  the  nostrils,  is  almost  invariably  in  association  with  adenoid 
overgrowths  of  the  pharyngeal  tonsil."  But  he  further  adds  that 
he  is  not  sure  that  the  purulent  catarrh  is  primary,  for  he  has  seen 
many  cases  in  which  removal  of  the  growths  has  led  to  a  speedy 
cure  of  the  discharge. 

Bosworth  says  that  this  trouble  should  be  looked  upon  as  a 
general  disease  with  marked  local  manifestations.  He  also  states 
that  "over  sixty  per  cent,  of  all  nasal  catarrh  in  children  is  due  to 
the  presence  of  these  growths,"  thus  indicating  his  belief  that  the 
nasal  catarrh  is  secondary  and  consequent  upon  the  adenoid 
growths. 

Adenoid  tissue  exists  normally  in  the  mucous  membrane  of  the 
naso-pharynx.  It  consists  of  a  fine  network  of  connective  tissue 
fi'brils  with  fixed  cells,  within  which  are  pale  blood  and  lymph  cor- 
puscles. 

There  appears  to  be  a  marked  analogy,  both  in  the  structure 
and  the  character  of  the  lesion,  between  the  pharyngeal  tonsil  and 
the  other  lymphoid  elements  of  the  naso-pharynx  and  the  faucial 
tonsils.  Dr.  Harrison  Allen  defines  adenoid  growths  as  papil- 
lomata,  containing  normal  lymphoid  tissue,  of  the  vault  of  the 
pharynx.  These  conclusions  of  Dr.  xA.llen  were  reached  after  he 
had  made  many  microscopical  sections  of  these  growths,  and  had 
observed  them  personally.  The  neoplasm  may  be  congenital, 
when  it  is  difficult  to  escape  the  conclusion  that  it  has  been  in 
some  way  associated  with  the  canal  which  is  found  in  early  fetal 
life  penetrating  the  brain-case  and  uniting  the  anterior  part  of  the 
pituitary  body  to  the  lining  membrane  of  the  pharynx.  Dr.  Allen 
has  removed  growths  the  size  of  a  filbert  from  a  child  six  weeks 
old,  in  which  the  naso-pharynx  was  completely  obstructed.  But 
these  growths  do  not  invite  scrutiny  in  infancy,  and  from  the  fact 
that  most  cases  come  to  notice  after  the  fifth  year  it  is  probable 


2l8  THE    PRACTICE    OF    DENTAL   MEDICINE. 

that  the  papillomata  at  the  vault  are  apt  to  take  on  a  hyperplastic 
condition  at  this  time,  or  a  little  later.  It  is  then  that  the  perma- 
nent teeth  are  beginning  to  erupt  and  the  altered  proportions  of 
the  face  and  associate  parts  announce  the  change  from  infancy  to 
childhood. 

Another  important  observation  by  Dr.  Allen  is  that  the  shape 
of  the  vault  may  determine  whether  the  growth,  normal  in  other 
respects,  interferes  with  the  functions  of  the  pharynx;  for  instance, 
if  the  angle  formed  between  the  basilar,  sphenoid,  and  vomerine 
processes  is  of  high  degree,  a  disadvantage  exists  for  the  pharynx 
to  maintain  its  patency. 

Symptoms.^ — Among  the  most  prominent  symptoms,  as  noted 
by  Sajous,  is  the  peculiar  deadness  of  the  voice,  due  to  impaired 
resonance  dependent  upon  nasal  obstruction.  It  is  a  muffled, 
thick  voice  accompanied  by  a  "nasal  twang." 

Dr.  Sajous  says  that  as  a  rule  the  nasal  respiration  is  not 
impeded,  but  when  the  growths  are  large,  a  feeling  of  obstruction 
is  experienced  and  breathing  through  the  mouth  is  established. 

The  open  mouth  and  stupid  expression  constitute  what  is 
termed  the  "adenoid  facies,"  and  is  held  by  some  to  be  a  sufifiicient 
diagnostic  sign.  Associated  with  these  facial  signs,  inattention  is 
often  apparent,  and  occasionally  deafness  exists. 

The  obstruction  to  respiration  interferes  with  sleep,  and  the 
child  never  sleeps  soundly,  has  frequent  dreams,  and  often  awakes 
suddenly  screaming  and  frightened. 

In  a  large  percentage  of  cases,  enlarged  faucial  tonsils  are  pres- 
ent, but  their  presence  or  absence  cannot  determine  the  diagnosis. 
The  chest  walls  are  often  depressed,  as  the  inspired  air  is  not  suffi- 
cient in  quantity  to  properly  expand  them.  Defective  develop- 
ment of  the  teeth  and  a  narrow  and  apparently  high  arch  are  also 
symptomatic. 

Prognosis.- — The  prognosis,  in  view  of  treatment,  is  highly 
favorable;  but  if  the  growths  are  left  to  their  natural  course,  the 
process  of  absorption  is  so  slow  that  a  great  amount  of  damage 
may  be  done  before  there  is  much  reduction  in  size,  and  therefore 
in  such  a  case  the  prognosis  is  less  favorable. 

It  is  obvious  that  adults,  who  have  suffered  for  a  greater 
length  of  time,  are  more  likely  to  have  such  serious  complications 
as  middle-ear  disease,  which  may  render  complete  recovery  doubt- 
ful. 


HYPERTROPHY    OF   ADENOID    TISSUE,    ETC.  219 

Course,  Duration,  etc. — Of  the  three  tonsillar  growths,  the 
pharyngeal  tonsil  develops  in  infantile  life,  and  is  more  frequently 
made  manifest  at  about  the  fifth  year,  continuing  until  puberty, 
when  by  absorption  it  is  gradually  reduced  in  size;  though  occa- 
sionally much  of  the  growth  may  remain  throughout  life. 

Next  in  order  of  appearance  and  disappearance,  is  the  faucial 
tonsil,  and  following  that  the  lingual  tonsil,  which  reaches  its 
highest  point  of  development  in  advanced  life. 

Diagnosis. — It  has  been  considered  by  many  that  on  the  whole 
the  diagnosis  is  easy.  This  may  be  true  in  a  comparative  degree, 
but  many  cases  are  deceptive. 

Many  authorities  rely  largely  upon  the  "adenoid  facies"  for 
diagnosis,  but  it  should  be  remembered  that  neither  the  face  nor 
the  dental  arches  afford  conclusive  evidence  of  this  disease. 
Neither  should  the  high  dental  arch,  deafness,  or  mouth-breathing 
alone  be  relied  upon  to  establish  a  diagnosis.  A  careful  study  of 
the  symptoms  will,  in  most  cases,  enable  one  to  make  a  tolerably 
good  guess,  but  this  should  only  form  the  basis  upon  which  you 
decide  to  make  further  and  decisive  examinations.  These  exami- 
nations consist  of  posterior  rhinoscopy  and  digital  exploration. 
When  the  former  is  not  practicable,  as  may  be  the  case  in  small 
children,  the  latter  means  may  be  employed.*  In  both  these  ex- 
aminations the  application  of  a  four  per  cent,  solution  of  cocain 
hydrochlorid  is  a  decided  advantage. 

It  should  be  remembered  that  in  many  children  there  is  nor- 
mally present  a  thickened  cushion  of  tissue  extending  over  the 
surface  of  the  pharyngeal  vault,  which  may  be  felt  wdth  the  finger 
and  which  may  even  encroach  to  a  slight  extent  on  the  lumen  of 
the  breathing  space.  This  should  not  be  mistaken  for  genuine 
adenoid  growths,  which  are  masses  of  soft  clusters  hanging  pend- 
ent from  the  vault,  and  cannot  be  mistaken  for  the  condition  of 
thickened  membrane  above  described.  Digital  exploration  then 
forms  the  conclusive  step  in  the  diagnosis.  To  one  who  is  familiar 
with  the  anatomy  of  the  parts,  and  whose  touch  is  expert  through 
practice,  it  cannot  fail  to  furnish  conclusive  evidence. 

Treatment. — The  treatment  is  mainly  surgical,  although  the 
medicinal  treatment  by  astringents  offers  hope.     The  recommen- 

*  The  author  rarely  uses  digital  exploration  at  the  present  time,  unless 
an  anesthetic  is  administered  for  this  purpose,  when,  if  the  growth  is 
present,  it  may  be  removed. 


220  THE   PRACTICE    OF    DENTAL    MEDICINE. 

dation  in  cases  of  slight  obstruction  by  soft  growths  in  children,  is : 
A  lotion  of  glycerite  of  tannin  to  be  syringed  along  the  inferior 
meatus  to  the  pharynx,  night  and  morning. 

The  surgical  method  has  two  objects  in  view:  First,  by  means 
of  scraping,  or  scarification,  to  cause  free  hemorrhage  and  conse- 
quent absorption.  Second,  a  complete  removal  of  the  growths. 
This  should  be  accomplished  if  possible,  for  the  reason  that  when 
this  is  done  there  is  little  prospect  of  recurrence. 

In  the  same  surgical  treatment  of  these  growths  a  large  variety 
of  instruments  is  used,  depending  upon  the  operator's  conception 
of  the  method  to  be  employed,  and  especially  upon  the  size  and 
character  of  the  growths,  these  conditions  being  governed  by  the 
age  and  condition  of  the  patient.  The  instrument  most  commonly 
employed  is  a  modification  of  Loewenberg's  forceps,  the  beaks  of 
which  have  been  greatly  enlarged  in  recent  years. 

In  infants,  the  growth  is  tender,  and  in  many  cases  may  be 
removed  by  the  finger-nail  (left  purposely  long  and  sharp).  The 
finger  may,  however,  be  armed  with  a  steel  finger-nail,  to  accom- 
plish the  same  thing,  when  it  is  deemed  advisable. 

Gottstein's  curette  has  been  modified  and  its  popularity  has 
increased  during  the  last  five  years. 

The  pharyngeal  tonsillotome,  recently  devised,  is  proving  to  be 
a  very  useful  instrument. 

There  are  also  various  cautery  instruments  which  may  be  used 
to  advantage  in  certain  cases  of  sufficient  age  to  permit  the  intro- 
duction of  the  instrument  into  the  pharynx,  and  in  which  the 
growths  are  not  large. 

The  methods  of  operating  are  also  various.  In  adults  cocain 
may  be  applied  and  the  growth  removed  at  one  or  several  sittings. 

A  commendable  method  is  that  in  which  the  patient  either  sits 
or  is  held  upright  after  being  etherized;  the  mouth  is  held  open 
with  a  Mason's  mouth-gag,  and  the  operator,  with  the  forceps  and 
palate  retractor,  proceeds  to  remove  the  growth.  Often  the  finger 
of  the  opposite  hand  may  be  used  to  guide  the  instrument.  As- 
sistants, with  forceps  armed  with  cotton,  stand  ready  to  remove 
blood  from  the  pharynx  as  soon  as  hemorrhage  occurs,  the  head, 
as  soon  as  the  forceps  are  removed,  being  carried  forward  to 
prevent  blood  from  going  down  the  throat. 

Nitrous  oxid  gas  is  often  a  sufficient  anesthetic,  and  in  many 
cases  the  operation  may  thus  be  completed  at  one  sitting. 


ADENOID    VEGETATIONS    AND    DENTAL    IRREGULARITIES.  221 

The  patient  should  keep  indoors  for  three  or  four  days  after  the 
operation,  avoiding  the  inhalation  of  dust;  after  which  time  the 
treatment  should  consist  of  nasal  and  post-nasal  sprays,  to  reduce 
catarrh  and  to  promote  healing  and  absorption  of  the  parts  op- 
erated upon. 


CHAPTER    XLV. 


THE   RELATION   OF   ADENOID   VEGETATIONS   TO    IRREGU- 
LARITIES OF  THE  TEETH  AND  ASSOCIATE    PARTS. 

The  following  statements  will  indicate  the  position  taken  in 
relation  to  the  subject  under  consideration: 

1.  Adenoid  growths  may  exist,  though  rarely,  without  mouth- 
breathing.  Mouth-breathing  may  exist  without  adenoid  growths, 
being  due  in  many  instances  to  a  chronic  hypertrophy  of  the  turbi- 
nated bodies  or  to  some  septal  deformity. 

2.  Mouth-breathing  is  the  result  of  the  irritation  due  to  the 
presence  of  adenoid  growths  in  the  pharyngeal  space,  rather  than 
to  the  obstruction  which  they  produce. 

3.  Mouth-breathing  does  not  produce  adenoid  vegetations. 

4.  Mouth-breathing  does  not  cause  irregularities  of  the  teeth. 

5.  Many  cases  present  deformed  arches  and  irregular  teeth,  in 
which  no  adenoids  exist. 

It  is  argued  by  G.  Macdonald  that  nasal  stenosis  is  a  constant 
factor  in  post-nasal  growths,  and  that  this  being  the  case,  "As 
long  as  respiration  is  conducted  through  the  nose,  there  is,  of  a 
physical  necessity,  a  diminution  in  the  barometric  pressure  behind 
the  seat  of  stenosis.  This  inevitably  results  in  more  or  less  over- 
filling of  the  bloodvessels,  which  in  its  turn  leads  to  hypernutri- 
tion  and  hypertrophy."  It  is  obvious  that  when  the  diaphragm  is 
depressed,  the  mouth  closed,  and  the  nose  partially  closed,  there  is 
more  or  less  suction  produced  which  would  draw  an  excess  of 
blood  to  the  pharyngeal  region;  but  according  to  the  writer's 
observations,  patients  breathe  through  the  mouth,  by  force  of 
habit,  even  when  it  is  possible  to  breathe  through  the  nose.  The 
swollen  turbinates,  with  their  rich  supply  of  nerves,  readily  convey 
a  sense  of  suffocation  to  the  brain,  and  the  mouth  is  immediately 


222  THE    PRACTICE    OF   DENTAL   MEDICINE. 

opened.  The  author  has  repeatedly  found  children  breathing 
through  the  mouth,  who  upon  request  to  breathe  through  the  nose 
were  able  to  do  so,  but  as  soon  as  their  attention  was  drawn  in  an- 
other direction  the  mouth  opened  and  mouth-breathing  was  con- 
tinued. Moreover,  the  mouth  opens  so  readily  upon  so  little 
provocation  from  the  nasal  irritation  and  stenosis,  that  it  does  not 
seem  possible  that  sufficient  "diminution  of  the  barometric  pres- 
sure" can  be  produced  in  the  pharyngeal  vault  to  cause  a  growth  of 
tissue.  This  view  also  necessitates  nasal  stenosis  to  begin  with, 
but  it  is  generally  understood  that  the  enlarged  turbinates  are  the 
result,  not  the  cause  of  the  adenoids,  and  observation  shows  that 
the  nasal  obstruction  gradually  disappears  after  the  removal  of  the 
growth.  Again,  this  will  not  account  for  the  congenital  growths, 
and  those  growths  in  infants  whose  respiration  has  only  been  estab- 
lished a  few  weeks  or  months;  and  again,  those  cases  of  nasal 
stenosis  of  long  standing  in  which  there  is  no  adenoid  hypertrophy. 
If  it  is  true  that  this  "diminution  of  the  barometric  pressure"  acts 
also  to  increase  the  size  of  the  faucial  tonsils,  how  shall  we  account 
for  many  cases  of  post-nasal  adenoids  in  which  the  faucial  tonsils 
are  normal?  Their  growth  and  development  are  acknowledged  to 
be  on  the  same  principle,  they  have  physiological  limitations  in 
common,  and  it  would  seem  reasonable  to  assign  a  common  cause 
to  both. 

It  has  been  said  that  adenoid  growths  in  the  pharyngeal  vault 
cause  irregularities  of  the  teeth,  but  it  would  seem  rather  that  the 
dental  irregularities  are  the  result  of  the  same  cause  that  operates 
to  produce  the  adenoid  growth;  in  other  words,  there  is  one  cause 
common  to  both,  yet  this  cause  may  not  be  able  in  all  cases  to  pro- 
duce both.  Deformities  of  the  hard  palate  are  frequently  asso- 
ciated with  adenoid  growths,  but  not  always,  as  many  would  give 
us  to  understand.  There  are  various  reasons  given  concerning 
the  origin  of  these  irregularities.  For  instance,  it  is  said  that  a 
so-called  high  arch  or  V-shaped  arch  is  a  diagnostic  sign  of 
adenoids  in  the  pharyngeal  vault.  The  late  Dr.  F.  H.  Hooper  in 
his  pamphlet  on  "Mechanical  Effects  of  Adenoid  Vegetations," 
says,  "The  hard  palate,  from  the  constant  atmospheric  pressure 
within  the  mouth,  is  pushed  upward." 

It  is  difficult  to  see  how  there  can  be  a  constant  pressure  within 
the  mouth  while  it  is  open  and  the  air  is  free  to  move  either  in  or 
out.     The  air  must  be  confined  in  a  given  space,  and  a  force  ex- 


ADENOID    VEGETATIONS    AND    DENTAL    IRREGULARITIES.  223 

erted,  in  order  that  pressure  in  any  direction  may  be  made.  There- 
fore we  cannot  believe  that  this  deformity  of  the  arch  is  due  to 
atmospheric  pressure  caused  by  nasal  stenosis. 

The  theory  of  David  which  accounts  for  the  deformity  of  the 
hard  palate  in  persons  suffering  from  nasal  stenosis,  is  that  a  par- 
tial vacuum  is  produced  in  the  nasal  cavities  and  upper  pharynx 
by  the  act  of  swallowing.  The  atmospheric  pressure  remaining 
the  same  in  the  mouth,  its  roof  is  pushed  upward.  It  is  difficult 
to  reconcile  this  theory  with  the  writer's  view  of  the  case.  In  the 
first  place,  it  must  be  a  rare  case  in  which  the  nasal  stenosis  is  so 
complete  that  a  partial  vacuum  would  be  produced  behind  it.  It 
is  well  known  that  in  the  act  of  swallowing  the  tongue  presses 
forcibly  against  the  roof  of  the  mouth  from  before  backward,  the 
soft  palate  is  slightly  raised,  the  posterior  pillars  of  the  soft  palate 
then  contract  on  either  side  of  the  uvula,  forming  a  nearly  perfect 
closure,  which,  with  the  application  of  the  superior  surface  of  the 
soft  palate  to  the  posterior  wall  of  the  pharynx,  forms  a  successful 
barrier  protecting  the  posterior  nares.  The  necessity  of  this,  as 
well  as  the  proof  of  this  function,  is  shown  in  cases  of  paralysis  of 
the  soft  palate,  in  which  liquids  swallowed  regurgitate  into  the 
nose. 

Now,  the  act  of  swallowing  is  momentary,  and  the  muscles  con- 
tract firmly,  and  it  does  not  seem  possible  for  this  temporary  dia- 
phragm to  be  so  pulled  downward  as  to  cause  a  partial  vacuum  in 
the  nasal  cavities.  Moreover,  immediately  after  swallowing  there 
is  a  reaction;  the  breath,  which  is  held  during  deglutition,  is  now 
expelled  with  some  force  through  the  nose,  the  mouth  being  closed 
in  the  act  of  swallowing.  If  the  air  does  not  find  exit  through  the 
nose  the  mouth  does  not  open  until  after  considerable  pressure, 
not  suction,  has  been  exerted  in  the  upper  pharynx  and  the  nose. 
This  may  be  demonstrated  by  occluding  the  nose  with  the  thumb 
and  finger,  and  performing  the  act  of  deglutition.  Again,  we 
cannot  account  for  asymmetrical  deformities  of  the  hard  palate  if 
they  are  caused  by  atmospheric  pressure,  for  the  pressure  must 
bear  on  all  parts  equally,  and  the  palatine  arch  should  be  pressed 
upward  equally  high  in  all  directions.  Fig.  35  shows  the  case  of 
Mr.  C,  aged  thirty-nine  years,  with  a  large  adenoid  growth  in  the 
pharyngeal  vault,  but  one  side  of  the  hard  palate  is  much  higher 
than  the  other  side. 

It  is  said  that  mouth-breathing  necessitates  a  constant  dropping 


224 


THE    PRACTICE    OF    DENTAL    MEDICINE. 


of  the  lower  jaw,  which,  in  so  doing,  causes  pressure  of  the  mas- 
seter  and  other  muscles  upon  the  buccal  surfaces  of  the  upper  teeth 
and  consequent  flattening  of  the  lateral  alveolar  arches  and  the 
projecting  forward  of  the  cuspids  and  incisors.  The  dropping  of 
the  lower  jaw  does  not  produce  pressure  on  the  teeth  in  the  supe- 
rior maxilla;  it  is  approximated  to  the  upper  teeth  principally  by 
tlie  masseter,  temporal,  and  internal  pterygoid  muscles,  and  when 
the  jaw  drops  by  the  relaxation  of  these  and  other  muscles  and 
tissues  of  the  face,  unless  the  mouth  be  open  to  the  fullest  extent 
by  the  action  of  the  platysma  myoides,  digastric,  and  other  mus- 
cles, the  tissues  of  the  cheek  are  not  put  upon  the  stretch, — in 
fact,  the  finger  can  be  easily  passed  in  between  the  teeth  and  the 

Fig.  35. 


Case  of  Mr.  C. 

jaw  without  being  sensible  of  any  pressure  upon  it,  provided  the 
mouth  is  not  opened  widely;  moreover,  it  is  reasonable  to  conclude 
that  the  jaw  is  held  suspended,  not  b)^  the  cheeks,  but  by  the  mas- 
seter and  accessory  muscles. 

The  cheeks  cover  the  jaws  and  teeth  loosely,  with  tissue  to 
spare,  and  will,  as  a  rule,  admit  of  the  jaws  being  opened  to  a  con- 
siderable extent  without  separating  the  lips  or  stretching  the 
cheeks  (this  is  often  the  case  during  sleep);  therefore  when  the 
lower  jaw  relaxes  sufficiently  to  let  air  in  through  the  mouth, 
it  cannot  put  the  tissues  of  the  cheeks  on  the  stretch  or  draw  them 
tightly  against  the  teeth.  Both  observation  and  experiment  will 
show  that  it  is  only  necessary  to  open  the  lips  slightly  in  order  to 
allow  sufficient  air  to  pass  in  by  the  mouth,  and  that  all  the  tissues 
concerned  are  in  a  relaxed  condition  while  the  mouth-breathing  is 
going  on.     In  order  to  demonstrate  this,  the  writer  made  a  num- 


ADENOID    \EGETATIOXS    AND    DENTAL    IRREGULARITIES. 


225 


ber  of  experiments  to  determine  the  pressure  of  tissues  and  muscles 
against  tlie  teeth.  The  device  which  was  found  most  successful 
is  illustrated  by  Fig.  36.  It  was  at  first  intended  for  the  little 
pointer  to  make  a  tracing,  but  this  w-as  unnecessary,  as  it  could  be 
observed  while  the  mouth  was  being  opened. 

The  use  of  this  mechanism  confirms  the  views  above  expressed; 
moreover,  the  anatomy  of  the  parts  involved  bears  the  same  testi- 
mony upon  careful  observation  and  study.  Notice  the  fact  that  a 
straight  line  drawn  from  the  point  of  origin  to  insertion  of  the 
masseter  muscle  would  not  touch  the  teeth.  A  profile  view  shows 
the  fact  that  the  masseter  extends  no  farther  forward  than  the  sec- 
ond molar,  while  the  other  muscles  concerned  do  not  even  come 
as  far  forward  as  that. 

Fig.  36. 

n       d 


a.  Flat  surface  soldered  to  the  movable  rod  b  c.  Pressure  of  the  cheek  being  made  upon 
a,  it  moves  the  pointer  rf,  which  is  also  soldered  to  the  rod  be.  e.  A  very  thin  strip  of  rubber 
dam,  to  hold  the  flat  surface  a  away  from  the  teeth,  but  not  enough  to  resist  the  slightest  pres- 
sure of  the  cheek  upon  it. 

Expansion  of  the  lower  arch  is  said  to  be  a  result  of  adenoids; 
reference  is  therefore  made  to  the  case  of  Airs.  H.,  aged  thirty,  with 
a  history  of  mouth-breathing  from  infancy,  with  a  marked  lateral 
contraction  of  tlie  lower  arch,  the  bicuspids  closing  entirely  inside 
the  upper  teeth.  The  nasal  breathing  w-as  fairly  free  at  this  time, 
yet  mouth-breathing  was  continued,  partly  from  habit  and  partly 
from  chronic  nasal  catarrh.  There  were  no  adenoid  growths  or 
enlarged  tonsils;  there  may  have  been  in  early  life,  but  the  one 
thing  to  be  noted  is  that  habitual  mouth-breathing  did  not  expand 
the  lower  arch  in  this  case. 

Dr.  Henri  Chatellier,  of  Paris,  calls  attention  to  the  bones  of 

16 


226 


THE    PRACTICE    OF    DENTAL    MEDICINE. 


the  head  and  face  as  afifected  by  obstructed  nasal  respiration.  He 
points  out  that  the  air-cavities  of  the  frontal,  sphenoidal,  ethmoidal, 
and  maxillary  bones,  being  normally  in  communication  with  the 
air,  cease  to  develop  when  the  circulation  of  air  through  the  nose 
is  interfered  with,  and  hence  the  normal  dimensions  of  the  face  are 
altered. 

Dr.  E.  S.  Talbot  says:  "There  are  many  cases  of  contracted 
arches  where  mouth-breathing  does  not  exist;  there  are  also  many 
cases  of  normal  arches  where  it  is  present."  In  substantiation  of 
this  statement  the  following  cases  are  presented,  both  having 
marked  adenoid  growths  and  consequent  nasal  stenosis  and  mouth- 
breathing,  but  in  which  the  dental  arches  present  a  striking  con- 
trast. 

Fig.  z7- 


Case  of  J .  H . 


Fig.  37  represents  a  cast  from  the  mouth  of  J.  H.,  aged  thir- 
teen years,  who  was  operated  upon  November  4,  1893,  a  large 
quantity  of  adenoid  tissue  being  removed.  The  marked  feature  in 
this  case  is  the  broad  and  regular  dental  arch. 

The  other  case,  E.  F.  (see  Fig.  38),  aged  nine  years,  was  oper- 
ated upon  a  week  later. 

As  long  ago  as  1879  there  appeared  a  paper  in  the  Philadelphia 
Medical  Times,  by  Prof.  Harrison  Allen,  in  which  he  says:  'Tnas- 
much  as  the  face  is  the  result  of  the  lateral  visceral  half-arches 
joining  the  median  structures  projected  from  the  front  of  the  brain- 
case,  it  follows  that  if  there  is  want  of  harmony  between  the  two 
genetic  movements,  errors  of  symmetry  will  readily  occur.  Expla- 
nation may  thus  be  given  of  asymmetry  of  the  nasal  chambers,  the 


ADENOID    VEGETATIONS    AND    DENTAL    IRREGULARITIES.  22/ 

external  nose,  the  two  halves  of  either  of  the  dental  arches,  en- 
tirely apart  from  the  acquired  defects  in  the  same  localities."  Ap- 
plying this  hypothesis  to  practice.  Dr.  Allen  had  recognized  a 
well-defined  group  of  cases  in  which  the  nasal  chambers  remained, 
from  birth,  partially  or  entirely  occluded. 

Also,  in  cases  of  obstinate  catarrh  in  children  from  seven  to 
eighteen  years  of  age,  in  whom  the  upper  permanent  incisors  were 
overlapping  and  convergent,  the  two  halves  of  the  upper  dental 
arch  more  or  less  V-shaped,  the  tonsils  tumid,  the  roof  of  the 
mouth  with  a  high,  narrow  vault,  he  found  that  the  cause  was  deep- 
lying  and  congenital,  and  affected  all  the  structures  of  the  face. 

Fig.  r,8. 


Case  of  E.  F. 

Dr.  Allen  has  frecjuently  noted  the  way  in  which  the  dental  arch  is 
narrowed  and  elevated  in  adults  in  whom  no  history  of  either 
adenoid  disease  or  nasal  obstruction  was  given. 

It  should  be  noticed  also  that  the  upper  incisors  approach  the 
vertical  position,  sometimes  overlapping,  in  many  cases  of  disease, 
while  in  thumb-suckers  these  teeth  protrude  from  the  mouth.  In 
a  clinical  lecture,  delivered  before  the  First  District  Dental  Society 
of  New  York,  Dr.  Allen  described  a  case  that  is  instructive,  as 
showing  the  possibility  of  the  Hutchinsonian  or  an  allied  deforma- 
tion of  the  teeth  occurring  without  a  history  of  syphilis  or  scarla- 
tina; that  oral  respiration  was  established  as  early  as  the  fifth  year, 
due  to  a  large  adenoid  growth;  that  the  teeth  were  congenitally 
deformed;  that  this  congenital  deformation  could  hardly  be  caused 
by  oral  respiration  established  at  the  fifth  year.  The  following 
description  and  remarks  concerning  the  above  case  are  given  by 
Dr.  Allen: 


228  THE    PRACTICE    OF    DENTAL    MEDICINE. 

A  lad  in  his  tenth  year  lately  came  under  my  observation  for  difficulty 
arising   from   oral   respiration.     He   was   the   son   of   respectable   parents; 

there  was  entire  absence  of  the  ordinary  signs  of  syphilis At  the 

fifth  year  it  was  observed  that  oral  respiration  became  established,  and  there 
was  also  a  disposition  to  take  cold  easily. 

Examination  of  the  pharynx  revealed  the  presence  of  a  large  adenoid 
growth  pendent  from  the  roof.  The  palatal  arch  was  high  and  narrow,  the 
obstruction  to  nasal  respiration  was  absolute.  The  nasal  septum  was  irregu- 
lar, apparently  due  to  enormous  thickenings  of  the  maxillary  crests.  The 
teeth  presented  all  the  characters  of  the  Hutchinsonian  deformity,  except- 
ing only  that  the  lateral  incisor  teeth  were  not  pegged. 

After  the  removal  of  the  adenoid  growth,  nasal  respiration  was  re- 
established. Now  what,  in  all  probability,  has  been  the  order  of  events  in 
this  case?  The  clinical  condition  which  brought  the  child  under  my  care 
was  not  announced  until  the  fifth  year.  Evidently  this  was  not  the  first 
factor.  So  far  as  the  shapes  of  the  teeth  are  concerned,  they  must  have 
arisen  at  a  period  certainly  not  later  than  at  the  time  when  the  enamel- 
organs  and  the  dentin  bodies  were  being  adapted  one  to  the  other.  In  a 
word,  the  shapes  of  the  teeth  as  seen  at  the  tenth  year  were  congenitally 
deformed. 

Secondly,  the  maxilla,  especially  in  the  alveolar  region,  must  have  been 
changed  by  the  presence  of  these  malformed  teeth.  It  is  scarcely  likely 
that  the  establishment  of  oral  respiration  at  a  period  so  late  as  the  fifth 
year  should  cause  an  elevation  and  narrowing  of  the  palatal  arch  and 
hyperostosis  of  the  maxillary  crests.  If  this  position  be  accepted,  a  nar- 
rowed, high,  palatal  arch,  with  thickened  alveolar  processes,  would  be  just 
as  apt  to  arise  because:  of  prenatal  forces  (the  same  that  caused  the  deforma- 
tion of  the  teeth)  as  to  be  created  by  the  establishment  of  oral  respiration. 

What,  then,  is  the  relation  which  adenoid  growths  bear  to 
irregularities  of  the  teeth? 

Certainly  neither  a  maternal  nor  a  paternal  relationship,  but 
rather  should  the  dental  irregularities  and  the  adenoid  growths  be 
classed  as  but  two  among  many  resultant  conditions  traceable  to 
some  constitutional  defect  the  influence  of  which  has  been  trans- 
mitted from  parents  to  children,  and  which,  as  a  rule,  depends 
rpon  accidental  or  acquired  causes  for  its  development. 


INDEX. 


Abnormal  products,  formation  of,  2;  dis- 
semination of.  2 

Abortion  from  operations  during  preg- 
nancy, 53 

Abrasion,  187;  arrest  of  development  caus- 
ing, 187;  changes  in  the  pulp  from, 
188;  definition  of,  187;  etiology  of,  187; 
extraction  of  teeth  a  cause  of,  187; 
mal-occlusion  causing,  187;  pathology 
of,  188;  smokers'  teeth  presenting,  188. 

Abrasions  in  stomatitis,  73 

Abscess,  alveolar,  followed  by  necrosis,  201 
of  the  pulp,  illustrations  of,  172,  173 

Absorption  of  inflammatory  products,   19 

Acetate  of  lead  in  hemorrhage,  57,  60 

Acid  solvents  in  necrosis,  203;  in  pyorrhea, 
120 

Aconite  in  local  anesthesia,  48;  in  necrosis, 
203;  in  neuralgia,  32;  in  pericement- 
itis,   177 

Adenoid  growths,  215;  relation  of,  to  hyper- 
trophy of  tonsils,  214;  to  irregulari- 
ties of  teeth,  221 

Administration  of  ether.  44;  of  nitrous  oxid, 

43 
After-effects  of  anesthesia,  47 
Age  and  sex  in  inflammation,  5;  influencing 

hysteria,    21 ;    in    stomatitis    herpetica, 

"I 
Air,  warm,  method  of  applying  in  hypersen- 
sitive dentin,  155 
Alcoholic  stimulants  in  hysteria,  27 
Alkaline  washes  in  dental  caries,  152 
Alum  in  hemorrhage,  59 
Ameboid  movements  of  the  leucocytes,  16 
Anesthesia,  33;  abst'nence  from  food  before, 
42;  after-effects  of,  47;  antiseptics,  use 
in,  42;  care  necessary  in,  34;  choice  of 
anesthetic  in,  35;   condition  of  patient 
in,  33;  conditions  of  safety  in,  33;  con- 
traindications to.  34;  degree  of,  neces- 
sary, 44;  dropsy  in  relation  to,  35;  ex- 
amination of  patient  before,  42;  exam- 
ination of  heart  in.  42;  of  mouth  in,  42; 
Fillebrown's    inhaler   for,    44;    gasping 


Anesthesia — 

respiration  in,  47;  headache  after,  47; 
heart  disease  contraindicating,  34;  h'c- 
cough,  its  significance  in,  47;  heart 
failure  in,  46;  hysteria  following,  47; 
instruments  to  be  in  readiness  before, 
42;  local,  47;  method  of  inducing,  43; 
morphin,  its  use  in,  47;  mouth-prop  a 
necessity  in,  43 ;  nausea  and  vomiting 
after,  47;  obstructions  to  breathing 
contraindicating,  34;  treatment  of  ob- 
structions to  breathing  in,  45,  46;  par- 
tial, a  source  of  danger,  45;  prepara- 
tion for  operation  before,  42;  position 
of  body  in.  43;  restoratives,  their  use 
in,  42;  sodium  bromid,  its  use  in,  47; 
stage  of,  during  pregnancy,  53;  stages 
of,  45;  suggestion,  its  use  in,  43;  treat- 
ment of  foreign  bodies  in  the  throat 
in,  46;  treatment  of  improper  position 
of  head  in,  46:  treatment  of  unfavor- 
able conditions  in,  45 

Anesthetic  agents:  A.  C.  E.  mixture.  33; 
chloroform  and  oxygen,  41 ;  choice  of 
agent,  35;  localities  where  chloroform 
is  used  most  frequently,  37;  reasons 
for  and  against  the  use  of  chloroform, 
38;  ether,  36;  ether  compared  with 
chloroform,  37;  ethyl  bromid.  39;  ex- 
perience necessarv  fcr  administr::t.cn, 
41 ;  method  of  administration.  41 ; 
nitrous  oxid,  35;  nitrous  oxid  and  oxy- 
gen, 36;  Schleich's  mixtures.  39;  use 
of  anesthetics  during  pregnancy,  53 

Ankylosis  of  the  jaw,  206;  after-efTects  of 
operations  fcr,  206;  definition  of,  206; 
eruption  of  wisdom  teeth  causing,  236; 
etiology  of,  206;  inflammatory  condi- 
tion causing,  206;  injuries  causing, 
206;  passive  motion  of  joints  in,  206; 
synovial  membrane,  its  inflammatory 
condition  in.  206;  treatment  of,  206; 
tuberculosis  causing,  206 

Antikamnia  in  pericementitis,  177 

Antiseptic  washes  in  stomatitis,  71 

Antitoxin  in  tetanus,  107 

229 


230 


INDEX. 


Bacillus  tetani,  104 

Bacteria,  action  of  heat  on,  13;  effect  of,  in 
acute  gastritis,  loi ;  on  white  blood- 
corpuscles,  18;  in  catarrhal  stomatitis, 
68;  in  dental  decay,  144;  in  the  blood,  3 

Bacteriological  examinations  in  tetanus,   107 

Bismuth  subnitrate  in  difficult  dentition,  134 

Blood,  bacteria  in,  3;  putrescent  fluid  in,  3 

Blood-cells,  migration  of,  15 

Bloodletting  in  pericementitis,   176 

Blood-serum,  modification  of,   18 

Brandy  in  hysteria,  27 

Breath  affected  in  pyorrhea,  119;  in  saliva- 
tion, 139 

Breathing,  obstructions  to,  45,  46;  treatment 
of,  45,  46     . 

c 

Calcareous  formations  in  ranula,  141 
Calcification  in  pulp-nodules,  manner  of,  193 
Calculi,  analysis  of,  in  pyorrhea,   116;  varie- 
ties in  pyorrhea,  112,  113 
Calomel  in  constipation,  (>2\  in  scurvy,  83 
Campho-phenique  in  phagedenic  pericemen- 
titis, 125 
Capping  pulps  in  acute  pulpitis,  168 
Capsicum  plasters  in  hyperemia  of  the  pulp, 

165 
Carbolic  acid  in  abscesses  of  the  pulp,   174; 
in    acute    pulpitis,    168;    in    gingivitis, 
no;  in  local  anesthesia,  48;  in  removal 
of  the  pulp,   19s;  in  salivation,   140;  in 
stomatitis,  i2\  uses  of,   no 
Caries    in    hypercementosis,    189;    compared 
with  necrosis,  202;   dental   (see   Dental 
caries) 
Cascara  sagrada  in  constipation,  62 
Castor  oil  in  difficult  dentition,  135 
Cataphoresis    in    hypersensitive    dentin,    158, 

160 
Catarrh,  its  significance  in  pyorrhea,  114 
Catarrhal  stomatitis   (see  Stomatitis) 
Catechu    in    hemorrhage,    59;    in    pyorrhea, 

121;  in  salivation,  140 
Cathartics  in  hyperemia  of  the  pulp,  165 
Caution     as    to    wearing    partial    plates    at 

night,  66 
Cell-migration,  13;  proof  of,  14;  vessels  con- 
cerned in,  13 
Chamomile  in  difficult  dentition,   135 
Chancroid,  94;  ciin'cal  history  of,  95;  defini- 
tion of,  94;  etiology  of,  95;  synonyms, 
94 
Chemotaxis,  17 

Chlorid  of  ethyl  in  hemorrhage,  59 
Chloroform  compared  with  other  anesthetic 
agents,    ZT\    in    hypersensitive    dentin, 
160;  with  oxvo-en,  41 
Cholera  infantum  in  difficult  dentition,   127 
Chorea  in  difficult  dentition,   129 


Circulation  in  inflammation,  15;  interrup- 
tion of,  causing  necrosis,  195 

Cleanliness  in  stomatitis,  68;  in  necrosis,  203 

Cleft  palate  in  relation  to  adenoid  growths, 
216 

Climate  in  rhachitis,  91;   in  stomatitis,  32 

Cocain,  caution  regarding  use  of,  48;  in 
hypersensitive  dentin,  157;  in  local 
anesthesia,  48;  in  rentoval  of  pulp,  195; 
in  removing  adenoids,  220;  Schleich's 
solutions  of,  49;  method  of  using,  49 

Cod-liver  oil  in  difficult  dentition,  135;  in 
neuralgia,  31;  in  rhachitis,  92;  in  rheu- 
matism, 99;  in  scrofula,  94;  in  stoma- 
titis, 78 

Cold  in  local  anesthesia,  78 

Constipation,  61;  calomel  in,  62;  cascara 
sagrada  in,  62;  diet  in,  62;  exercise 
in,  61;  inflammation  dependent  on,  61; 
magnesium  sulfate  in,  62;  massage  in, 
62;  pain  resulting  from,  61;  its  relation 
to  treatment  of  dental  diseases,  61; 
water  in,  62 

Constitutional  symptoms  of  inflammation, 
11;  in  brain,  12;  in  digestive  organs, 
12;  in  eyes,  12;  fever,  11;  pulse,  11,  12; 
temperature,  12 
treatment  in  gangrenous  stomatitis,  82; 
in  hypersensitive  dentin,  159;  in  neu- 
ralgia, 31 ;  in  phagedenic  pericement- 
itis, 125;  in  stomatitis  hyphomycetica, 
78;  in  tetanus,  108;  in  ulcerative  stoma- 
titis, 80 

Controlling  the  heart  in  hemorrhage,  60 

Convulsions  in  difficult  dentition,  126,  128; 
in  hysteria,  24 

Counter-irritation  in  pericementitis,   176 


Dental  caries,  144;  alkaline  washes  in,  152; 
bacteria  in,  145;  chewing-gum  in,  152; 
color  of  affected  structures  in,  146; 
direction  of  decay  in,  146;  essential 
factors  in,  144;  etiology  of,  144;  exer- 
cise of  teeth  in  treatment  of,  151;  food 
m  relation  to,  151 ;  general  diseases, 
contributory  causes  of,  146;  heredity 
in,  146;  history  in,  144;  illustrations  of 
decay  in,  147,  148,  149,  150;  lactic  acid 
in,  145;  "milk  of  magnesia"  in,  152; 
mouth-washes  in,  152;  oral  fluids  in, 
145;  pathology  of,  146;  position  of  the 
teeth  in  relation  to,  145;  predisposing 
causes  of,  145;  pregnancy  in  relation 
to,  146;  silver  nitrate  in,  152;  synonyms 
of,  144;  syrup  of  hypophosphites  of 
lime  and  soda  in,  152;  treatment  of, 
151 
erosion,  182;  acid  fruits  and  drinks 
causing,  182;  classification  of,  184;  con- 


INDEX. 


231 


Dental  erosion — 

stitutional  conditions  in,  183;  consti- 
tutional treatment  of,  185;  definition 
of,  182;  diet  in  constitutional  treat- 
ment of,  185;  effervescent  citrate  of 
lithium  in,  187;  etiology  of,  182;  exam- 
ination of  bodily  secretions  in,  1S5;  ex- 
amination of  secretions  from  mucous 
follicles  of  lip  in,  184;  exercise  in  treat- 
ment of,  186;  filiing  eroded  cavities  in, 
184;  gouty  diathesis  in,  183;  hyper- 
acidity of  the  saliva  in,  182;  "milk- of 
magnesia"  in,  185;  mineral  waters  in, 
186;  objects  of  treatment  in,  186; 
potassium  sulphocyanid  causing,  183; 
prognosis  of,  183;  shape  of  eroded  sur- 
faces in,  184;  source  of  acid  in,  182; 
symptoms  and  diagnosis  of,  184;  tar- 
tarlithine  in,  187;  test  of  oral  fluids  in, 
1S2;  treatment  of,  184;  water  in  treat- 
ment of,  187 

Dento-alveolar  abscess,  178;  absorption  in, 
178;  amount  of  pus  in,  179;  "blind 
abscess"  form  of,  179;  definition  of, 
178;  diagnosis  of,  180;  discoloration 
of  teeth  in,  179;  escape  of  pus  in, 
178;  escape  of  .pus  into  maxillary 
sinus  in,  179;  etiology  of,  178;  evacua- 
tion of  pus  in,  181 ;  gum  tissue  affected 
in,  iSo;  looseness  of  teeth  in,  180;  loss 
of  periosteum  in,  179;  pain,  its  charac- 
ter in,  i£o;  pathology  of,  178;  peri- 
cementum affected  in,  178;  prognosis 
of,  180;  signs  of  pus  in,  180;  strychnin 
in,  181;  symptoms  of,  179;  treatment 
of,  i8i 

Deposit,  location  of,  in  secondary  dentin, 
192 

Diabetes  causing  pyorrhea,   118 

Diagnosis,  differential,  2 

Diapedesis  of  white  cells,   15 

Diarrhea,  its  significance  in  difficult  denti- 
tion, 126 

Diathesis,    hemorrhagic,    55;    blood    in,    56; 
heredity  in,  56;  how  induced,  56;  warn- 
ing of,  56 
in  neuralgia,  29;  in  pyorrhea,   117,  118 

Diet  in  necrosis,  2C3;  in  neuralgia,  31;  in 
rheumatism,  99 

Differential  diagnosis,  2;  how  made,  2 

Difficult  dentition,  126;  definition,  126;  ar- 
guments for  and  against  lancing  gums 
in,  131 ;  bicarbonate  of  sodium  in, 
134;  bismuth  subnitrate  in,  134;  castor 
'oil  in,  135;  chamomile  in,  135;  cholera 
infantum  in  relation  to,  127;  chorea  in, 
129;  cod-liver  oil  in,  135;  constipation 
in,  13s;  convulsions  in,  126;  diarrhea 
in,  128,  135;  diarrhea,  its  significance 
in,    126;    eruption    of    deciduous    teeth 


Difficult  dentition — 

in,  126;  gums  affected  in,  128;  ice  in 
treatment  of,  133;  iron,  its  use  in,  133; 
lancing  the  gums  in,  130;  method  of 
lancing  in,  131;  opium  in,  134;  physio- 
logical re'.ations  of  the  mouth  in,  126; 
paraplegia  in,  129;  potassium  bromid 
in,  133;  reflex  irritations  in,  128,  129; 
rhubarb  in,  134;  sod.um  bromid  in, 
133;  sympathetic  relations  in  pathol- 
ogy of,   127;  temperature  in,   129 

Diphtheria,  83;  bacillus  in,  83;  breath  in, 
83;  contagious,  S3;  definition  of,  83; 
diagnosis  of,  83;  etiology  of,  83;  for- 
maldehyde in,  84;  incubation,  period 
of,  83;  Klebs-Loeffler  bacillus  causal 
agent  in,  83;  lactic  acid  in,  84;  mem- 
brane of,  described,  84;  mode  of  con- 
veyance of,  83;  stimulants  in,  84; 
symptoms  of,  83;  temperature  in,  S3; 
tongue  in,  83;  tonsils  in,  83;  treatment 
of,  84 

Discoloration  in  inflammation,  9 

Diseases,  course  of,  2;  history  of,  2;  suc- 
cessful treatment  of,  2 

Disordered  function  in  inflammation,  11; 
examples  of,   11 

Dobell's  solution  in  empyema  of  the  an- 
trum,  213 

Dosage  in  idiosyncrasy,  4 

Dropsy,  significance  of,  35 

Dyspepsia,  100;  as  a  descriptive  term  in 
general  use,  ico;  frequency  of,  100 

Eczema  confounded  with  scurvy,  90 
Electric  light  in  exploring  the  antrum,  213 
Electricity  in  rheumatism,  32 
Electrolytic  needle  in  hemorrhage,  59 
Empyema  of  the  maxillary  sinus,  207;  alve- 
olar abscess  causing,  2C7;  bilateral  dis- 
charge from  nose  in,  210;  boric  acid 
in,  213;  curettement  in,  213;  definition 
of,  207;  diagnosis  of,  210;  Dobell's  so- 
lution in,  213;  ethmoidal  cells,  their 
connection  with  the  antrum  account- 
ing for,  207;  etiology  of,  207;  frequent 
dental  origin  of,  208,  209;  frontal  sinus, 
its  connection  with  the  antrum  ac- 
counting for,  207 ;  general  health  in, 
213;  intra-nasal  disorders  causing,  208; 
intra-nasal  tumors  causing,  208;  meth- 
ods of  gaining  entrance  to,  212;  nasal 
or  dental  diseases  causing,  207;  nasal 
passages  affected  in,  209;  odor  of  dis- 
charge from,  210;  opening  through 
canine  fossa,  when  justifiable  in,  213; 
pain  in,  209;  pathology  and  symptoms 
of,  209;  peroxid  of  hydrogen  in  diag- 
nosis of,   211,   213;   principles   of  treat- 


232 


INDEX, 


Empyema  of  the  maxillary  sinus  — 

ment,  212;  pus  in,  210;  septa  in  antral 
chamber  in  relation  to,  212;  sounding 
in  diagnosis  of,  211;  swelling  in,  209; 
syphilitic  ulceration  in,  213;  teeth  per- 
forating the  antrum  in,  208;  transil- 
lumination in,  210,  211;  treatment  of, 
212 

Ergot  in  hemorrhage,  57,  60 

Erosion  of  the  teeth,  182;  in  neuralgia,  29; 
in  rheumatism,  99  (see  Dental  Erosion) 

Eruption  of  deciduous  teeth  in  difficult  den- 
tition, 126 

Esophagotomy  for  foreign  bodies  swallowed, 
65,  66 

Ether  as  an  anesthetic  agent,  36;  administra- 
tion of,  41 ;  compared  with  chloroform, 
ZT,  3S;  spray  in  hypersensitive  dentin, 
159;  by  iniialation  in  hypersensitive 
dentin,   159;  in  local  anesthesia,  48 

Ethyl  bromid   in  hypersensitive  dentin,    160 
chlorid  in  hypersensitive  dentin,  159;   in 
local  anesthesia,  48 

Eucain  in  local  anesthesia,  48;  writer's  ex- 
periments with,  48 

Exciting  causes,   definition   of,  4;    classifica- 
tion of,  6;   examples  of,   6 
stage  of  anesthesia,  45 

Exercise  for  constination,  61 

Exhaustion  in  scurvy,  85 

Experiments  showing  migration  of  cells,   15 

Exposure  of  pulp  in  pulpitis,  166 

Extension  of  inflammation,  7;  by  the  blood, 
8;  by  contiguity  of  structure,  8;  by 
continuity  of  structure,  8;  by  lym- 
phatics, 8;  by  nervous  system,  8; 
rapidity  of,  8 

Extraction  of  teeth  in  neuralgia,  29;  causing 
abrasion,  187 

Eyes,   examination  of,  in  neuralgia,  30 


Facial  expression  in  tetanus,  105 

Fatty   degeneration   of  heart   in   relation   to 

anesthesia,  34 
Fear  causing  syncope,  20 
Fever  in  catarrhal  stomatitis,  69 
Fillebrown's  apparatus  for  maintaining  an- 
esthesia, 44 
Fluids  of  the  mouth  in  stomatitis,  73 
Food  in  catarrhal  stomatitis,  70;  in  stomati- 
tis hyphomycetica,  78;  in  dental  caries, 
iSi 
Formaldehyde  gas  in  diphtheria,  84 
Formalin  in  abscess  of  pulp,   174 
Fowler's  solution  in  chronic  gastritis,   102 
Functions  in  health,  importance  of  a  knowl- 
edge of,  2 


Gallic  acid  in  hemorrhage,  60 
Galvano-cautery  in  hemorrhage,  59 
Gangrenous    stomatitis,    81 ;    appearance    of 
skin    in,    81 ;    constitutional    treatment 
of,  82;  definition  of,  81;  destruction  of 
tissue   in,   82;    etiology   of,   81;    micro- 
organisms   in,    81;    nitric   acid   in,   82; 
pathology   of,    81 ;    potassium    chlorate 
in,  82;  prognosis  of,  82;  symptoms  of, 
81 ;  synonyms  of,  81 ;  treatment  of,  82 
Gardner's  case  of  swallowing  a  plate,  63 
Gases,  pressure  of,  in  pericementitis,   175 
Gastritis,  acute,  ico;  bacteria  in,  loi ;  breath 
in,   loi ;  etiology  of,  100;  frequency  of, 
199;  mouth  as  a  focus  for  bacteria  in, 
loi;   nausea   in,    loi ;    regulating   appli- 
ances   causing,    loi ;    respiration    con- 
veying bacteria  in,   loi ;   symptoms  of, 
loi ;  teeth  containing  bacteria  in,   101; 
tongue  in,  loi;  tonsils  containing  bac- 
teria in,   loi 
chronic,     loi ;     its     effect     upon     teeth, 
102;  etiology  of,  loi ;  Fowler's  solution 
in,  102;  hygiene  of  the  mouth  in,   103; 
lack   of   teeth    in,    103;    mastication    in 
relation  to,   102;  "skimmed  milk  cure" 
of,    102;    symptoms    of,    102;   treatment 

of,    102 

Gastrotomy  for  removing  foreign  bodies,  63 
Gelsemium  in  neuralgia,  32 
General  considerations  in  pathology,  i 
Gingivitis,    109;   carbolic  acid   in,   no;    mer- 
cury   causing,     109;     potassium    iodid 
causing,   109;  scurvy  confounded  with, 
109;  tincture  of  catechti  in,  no 
Gooch's  case  of  swallowing  a  knife,  64 
Goulard's  extract  in  salivation,  140 
Grape-juice  in  scurvy,  86 

H 

Hard  palate,  deformities  of,  in  relation  to 
adenoid  growths,  222 

Heart-disease  contraindicating  anesthesia, 
34 

Heart-failure  in  anesthesia,  46 

Heat,  beneficent  action  of,  12;  effect  of,  on 
micro-organisms,  12,  13;  in  hypersen- 
sitive dentin,  155;  in  inflammation,  12; 
in  local  anesthesia,  48 

Hemophilia,  55;  causes  of,  55;  acquired,  56 

Hemorrhage,  54;  acetate  of  lead  in,  57,  60; 
alum  in,  59;  blood,  its  character  in,  56; 
catechu  in,  59;  constitutional  treat- 
ment of,  59;  controlling  the  heart  in, 
60;  definition  of,  54;  description  of  a 
case  of,  57;  electrolytic  needle  in,  59; 
ergot  in,  57,  60;  ethyl  chlorid  in,  59; 
etiology  of,  55;  following  extraction  of 


INDEX. 


233 


Hemorrhafi:e — 

teeth,  55;  following  tonsillotomy,  215; 
gallic  acid  in,  60;  galvano-cautery  in, 
59;  heredity  in,  56;  ice  in,  58;  in 
necrosis,  204;  kino  in,  59;  leading 
indications  in,  57!  Monsel's  solution 
in,  55;  myrrh  in,  59;  normal,  55; 
opium  in,  58.  60;  posture  in,  61; 
pressure  in,  58;  preventive  treatment 
oi,  57',  removal  of  clot  in,  58;  sec- 
ondary, 55,  58;  styptics,  injurious  ac- 
tion of,  55 ;  tannin  in,  58;  treatment 
of,  57;  wax  in,  58,  59. 

Heredity  in  dental  caries,  146;  in  hemor- 
rhagic diathesis,  56;  in  hysteria,  21; 
in  neuralgia,  28;  in  rhachitis,  91;  in 
scrofula,  92 

Hiccotigh  in  anesthesia,  47 

History  of  disease,  how  learned,  2;  of  dental 
caries,  144 

Hydrogen  peroxid  causing  necrosis,   198 

Hydrophobia  compared  with  tetanus,  106 

Hyoscyamus  in  neuralgia,  32 

Hypercementosis,  188;  caries  causing,  189; 
cemental  tissue,  190;  definition  of,  18S; 
etiology  of,  188;  form  of  irritation 
causing,  189;  illustration  of,  191;  man- 
ner of  formation  of,  189;  pathology  of, 
189;  ipynonyms  of,  188;  teeth  most  fre- 
quently affected  with,  189;  vitality  of 
the  pulp  in,  189 

Hyperemia  of  the  dental  pulp,  161 ;  capsi- 
cum plasters  in,  165;  cathartics  in,  165; 
definition  of,  i6i ;  diagnosis  of,  165; 
distension  of  vessels  in,  164;  duration 
of,  164;  etiology  of,  161;  pain  in,  164; 
pathological  condition  of  vessels  in, 
162;  pathology  of,  162;  prognosis  of, 
165;  sensitiveness  to  thermal  changes 
in,  162;  symptoms  of,  164;  treatment 
of,  165;  vasomotor  system  of  nerves, 
its  action  in,  163 

Hypersensitive  dentin,  153;  acid  secretions 
causing,  153;  carbolic  acid  in,  155; 
cataphoresis  in,  158;  ( — kind  of  battery 
for,  158;  — manner  of  applying  cur- 
rent, 159;  — method  of  producing,  158; 
— number  of  volts  used,  158; 
— strength  of  cocain  solution,  159) ; 
chloroform  in,  160;  cocain  in,  157; 
cocain  in  the  nostrils  in,  157;  consti- 
tutional treatment  in,  159;  definition 
of,  153;  ether  in,  159;  ether  by  inhala- 
tion in,  159;  ethyl  bromid  in,  160; 
ethyl  chlorid  in,  159;  etiology  of,  153; 
heat  in,  155;  hypnotism  in,  154;  instru- 
ments in,  154;  irritability  of  nervous 
system  in,  153;  local  conditions  in, 
153;  menstrual  period  in  relation  to, 
160;    nitrous    oxid    gas    in,    160;    pain, 


Hypersensitive  dentin — • 

how  induced  in,  153;  "Robinson  rem- 
edy" in,  157;  sodium  bicarbonate  in, 
159;  sodium  bromid  in,  160;  sugges- 
tion in,  154,  160;  treatment  of,  154; 
veratria  in,  157;  warm  air,  method  of 
applying  in,  155;  zinc  chlorid,  method 
of  applying  in,  155,  156 

Hypertrophy  of  adenoid  tissue,  215;  after- 
treatment  in  operation  for  removal  of, 
221 ;  anesthetics  in  operation  for  re- 
moval of,  220;  causing  nasal  catarrh, 
217;  cleft  palate,  its  relation  to,  216; 
cocain  in  operation  for  removal  of, 
220;  congenital,  217;  definition  of,  215; 
development  of  tonsillar,  219;  diagno- 
sis of,  219;  digital  exploration  of,  219; 
etiology  of,  216;  faucial  tonsils  en- 
larged in,  218;  heredity  in,  216;  his- 
tory in,  215,  217;  instruments  for 
operation  in,  220;  in  the  negro,  216; 
normal  growths  in  relation  to,  217; 
operation,  method  of,  220;  prognosis 
of,  218;  scrofulous  diathesis  in,  217; 
sleep  imperfect  in,  218;  stupid  expres- 
sion in,  218;  symptoms  of,  218;  syno- 
nyms of,  215;  taking  cold  causing,  217; 
tonsillar,  219;  treatment  of,  219;  voice 
affected  in,  218 
of  the  faucial  tonsils,  214;  age  in  rela- 
tion to,  214;  anesthesia  in  relation 
to,  215;  disturbed  sleep  in,  214; 
fetor  of  breath  in,  214;  hemorrhage 
after  operation  for  removal  of,  215; 
mouth-breathing  visual  in,  214;  muffled 
voice  in,  214;  scrofulous  diathesis  caus- 
ing, 214;  symptoms  of,  214;  treatment 
of,  214;  relation  of  adenoid  growths 
to,  214;  relation  of  uric  acid  diathesis 
to,  214 

Hypnotism  in  hypersensitive   dentin,    154 

Hypophosphites  of  lime  and  soda  in  rhach- 
itis, 92 

Hysteria,  age  in  relation  to,  21;  alcoholic 
stimulants  rarely  to  be  used  in  at- 
tacks, 27;  convulsions  in,  24;  diagnosis 
of,  25;  discipline  in  treatment  of,  26; 
definition  of,  21;  dental  causes  of,  22; 
duration  of,  25;  etiology  of,  21;  fol- 
lowing anesthesia,  47;  globus  hysteri- 
cus in,  24;  heredity  in,  21;  in  relation 
to  hypnotism,  23;  mental  constitution 
in,  21;  mental  strain  in,  22;  mimicry 
in,  24,  25;  occupation  in,  22;  overwork 
in,  22;  pathology  of,  22,  23;  phantom 
tumors  in,  25:  prognosis  of,  25;  rela- 
tion of  uterus  to,  22;  sex  in  relation 
to,  22;  shock  in,  22;  sodium  bromid 
in,  27;  sympathy  in,  22;  symptoms  of, 
24;   symptoms   of,    in   classes,   24;   the 


234 


INDEX. 


Hysteria — 

"Jumpers"  as  instances  of,  23;  treat- 
ment of,  26;  tuberculous  diathesis  in 
relation  to,  21;  valerian  in,  27;  water 
in  treatment  of,  27 

Hysterical  contraction  of  muscles  in  tetanus, 
ic6  • 


Ice  in  treatment  of  hemorrhage,  51,  58 
Idiosyncrasy,  3;  action  of  food  and  medi- 
cines in,  3;  definition  of,  3;  dosage  in, 
4;  ether  in,  3;  fish  in,  3;  honey  in,  3; 
illustration  of,  3;  mercury  in,  3; 
nitrous  oxid  in,  3;  opium  in,  3;  watch- 
fulness regarding,  4 
Illustrations   of  dental   caries,    147,    148,    149, 

ISO 
Impacted  teeth   in  neuralgia,   31 
Indifferent  fluid,  15 

Inflammation,  4;  accompanying  necrosis, 
2co;  acquired  predisposing  causes  of, 
5 ;  acute,  6 ;  age  and  sex  in,  5 ;  attrac- 
tion and  repulsion  of  blood-cells  in, 
18;  brain  in,  12;  cell-migration  in,  13; 
chronic,  6;  climate  in,  5;  constitu- 
tional symptoms  of,  11;  definition  of, 
4;  destruction  of  tissue  in,  7;  digestive 
organs  in,  12;  discoloration  in,  9;  dis- 
ordered function  in,  11;  dress  in,  s; 
effect  of,  on  blood-cells,  on  circulation, 
and  on  bloodvessels,  13,  14;  etiology 
of,  4;  exciting  cause  of,  defined,  4; 
exciting  causes  of,  6;  extension  of,  7; 
experiments  showing  natvire  of,  15; 
heat  in,  12;  inflammatory  exudation  in, 
14;  intimate  nature  of,  12;  legitimate 
function  of,  7;  leucocytes  in,  13;  modes 
of  extension,  8;  muscles  in,  12;  natural 
predisposing  causes  of,  4;  occupation 
in,  5;  pain  in,  9;  phagocytosis  in,  18; 
poisons  generated  in,  7;  predisposing 
causes  of,  defined,  4;  pulse  in,  12; 
purpose  of  cell-migration  in,  18;  pus 
in,  18;  rapidity  of  extension  of,  8; 
removal  of  inflammatory  products  in, 
19;  season  in  relation  to,  6;  septic,  7; 
swelling  in,  13;  symptoms  of,  9,  10, 
11;  termination  of,  7,  19;  traumatic,  7; 
varieties  of,  6 

Inflammatory    condition    causing    ankylosis 
of  the  jaw,  206 
process  in  general,  4;   illustration  of,  in 

pulpitis,   166 
products,  pressure  of,  in  pericementitis, 
175 

Influence  of  pathological  processes,  2 

Inhaler,  Fillebrown's,  44 

Injections  in  necrosis,  203 

Injuries  causing  ankylosis  of  the  jaw,  206 


Instruments  needed  in  operations  under  an 

anesthetic,  42 
Intra-cerebral  injection  in  tetanus,   107 
lodin,  tincture  of,   in  pericementitis,    177 
Iron  in  neuralgia,  31;  in  rhachitis,  92 

iodid  in  difficult  dentition,  133;  in  rheu- 
matism, 99 

J 
"Jumpers,"  the,  and  hysteria,  23 

Kidney  disease  causing  pyorrhea,   116 
Kino  in  treatment  of  hemorrhage,  59 
Klebs-Loeffler  bacillus  in  diphtheria,  83 


Lactic  acid  in  diphtheria,  84;  in  dental 
caries,  145 

Laxatives  in  necrosis,  203 

Leach's  case  of  swallowing  a  plate,  63 

Leeches  in  pericementitis,  176 

Lemon-juice  in  scurvy,  86 

Leucocytes,  ameboid  movements  of,   16 

Life,   simple  forms  of,  2 

Lime-water  during  pregnancy,   54 

Lithium  in  rheumatism,  100;  citrate  in  den- 
tal erosion,  187 

Local  anesthesia,  47;  aconite  in,  48;  carbolic 
acid  in,  48;  cocain  in,  48;  cold  in,  48; 
ether  in,  48;  ethyl  chlorid  in,  48; 
eucain  in,  48;  heat  in,  48;  method  of 
injecting,  49,  50;  method  of  inducing, 
48;  operations  under,  50;  Schleich's 
solutions  in,  49;  tropacocain  in,  48; 
uses  of,  50 

Lymph-corpuscles,  their  similarity  to  other 
cells,   19 

TO. 

Magnesium  sulfate  for  constipation,  62 
i\lal-occlusion  in  abrasion,  1S7 
Massage  for  constipation,  62 
Mastication,  effect  of,  on  the  teeth,   102 
Medicines,  action  of,  causing  necrosis,  196 
Membrane  in  diphtheria,  description  of,  84 
Menstruation,    51 ;    affecting   hypersensitive- 
ness  of  dentin,  159;  appointments  dur- 
ing, 51;   definition  of,  51;   duration  of, 
51 ;   effects   of,   on  the  general   system, 
51;  first  appearance  of,  51;  vicarious,  52 
Mental  condition  in  scurvy,  85 
Mercury  causing  gingivitis,   109 
Method  of  administering  anesthetic  agents, 
41 ;   examination  of  heart  and  respira- 
tion,   42;    food,    abstinence    from,    42; 
instruments     needed,     42;     medicines 
needed,   42;   position   of  the  body,   43; 
qualifications    of   the   anesthetizer,    41; 
suggestion,  43 
Micro-organisms  in  pyorrhea,  112;  in  phage- 
denic pericementitis,   122 


Migration  of  cells,  13;  time  consumed  in, 
15;  vessels  concerned   in,   13 

Milk  of  magnesia  during  pregnancy,  54;  in 
dental  erosion,  185 

Mimicry  in  hysteria,  24,  25 

Mineral  waters,  their  use  in  dental  erosion, 
186 

jMiscarriage  from  operations  during  preg- 
nancy, S3 

Mold  fungi  in  stomatitis,  74 

Monsel's   solution  in  hemorrhage,   55 

Morphin  in  tetanus,  108;  after  anesthesia,  47 

Mouth-breathing  in  relation  to  irregularilies 
of  the  teeth,  221 

Mouth-prop,  tise  of,  43 

Myrrh  in  treatment  of  hemorrhage,  59 


PJ 


jNasal  disorders  causing  antral  disease,  207 
Nausea  and   vomiting  following   anesthesia, 

47 

Necrosis,  195;  acid  solvents  in  treatment  of, 
203 ;  aconite  in,  203 ;  action  of  medi- 
cines in,  196;  age  in  relation  to,  196; 
alveolar  abscess  followed  by,  201 ;  alve- 
olar process  destroyed  by,  200;  anti- 
septic injections  in,  203;  aromatic  sul- 
furic acid  in,  203;  bones  most  fre- 
quently attacked  by,  196;  carious  teeth 
causing,  197;  circulation  of  blood 
in  relation  to,  195;  cleanliness  in 
treatment  of,  203;  co.mpared  with 
caries,  202;  definition  of,  195;  degen- 
erative changes  causing,  196;  deposits 
of  secondary  dentin  causing,  196;  diag- 
nosis of,  2C2;  diet  in,  203;  etiology  of, 
195;  exercise  in  treatment  of,  203;  ex- 
foliation in,  200;  general  symptoms  of, 
199;  hemorrhage  in,  204;  hydrogen 
peroxid  causing,  198;  impacted  teeth 
causing,  197;  impaired  function  from, 
201;  inflammation  in,  200;  laxatives  in, 
203;  local  irritation  causing,  196; 
opiates  in,  203;  pain  in,  200;  pathology 
of,  199;  periosteum  destroyed  in,  200; 
phosphorus  causing,  196;  preference 
for  lower  jaw  in  phosphor-necrosis, 
196;  probe,  its  use  in  diagnosis  of, 
202;  prognosis  of,  201;  progress  of, 
200;  pus  in,  199;  removal  of  seques- 
trum in,  204;  removal  of  teeth,  its  ad- 
visability in,  205;  sequestrum,  200;  soft 
parts  affected  in,  199;  strumous  diath- 
esis in  relation  to,  204;  symptoms  of, 
200;  teeth  affected  in,  200;  treatment 
of,  203 

Nervous  system  affected  during  pregnancy, 
51;  irritability  of,  in  hypersensitive 
dentin,  153 


INDEX.  235 

Neuralgia,  27;  aconite  in,  32;  arsenic  in,  31; 
climate  in,  32;  cod-liver  oil  in,  31; 
definition  of,  27;  diagnosis  of,  30; 
diathesis  in,  29;  diet,  31;  electricity  in, 
32;  etiology  of,  27;  examination  of 
eyes  in,  30;  examination  of  nose  in, 
30;  excessive  drinking  in,  28;  extrac- 
tion of  teeth  in,  29;  gelsemium  in,  32; 
heredity  in,  28;  hyoscyamus  in,  32; 
iron  in,  31;  location  of  pain  in,  29; 
narcotics  in,  30;  nerve-branches  af- 
fected in,  30;  opium  in,  32;  pain  in,  29; 
paroxj'sms  of,  how  induced,  29,  30; 
pathology  of,  27;  potassium  iodid  in, 
31;  quinin  in,  31;  sleep  in,  32;  sun- 
shine in,  32;  symptoms  of,  29;  tender 
spots  in,  29;  treatment  of,  30 
in  hypercementosis,  191 

Nitrate  of  silver  in  dental  caries,  152;  in 
pyorrhea,  122;  in  salivary  fistula,  136; 
in  stomatitis,  70 

Nitric  acid  in  pyorrhea,  82 

Nitrous  oxid  as  an  anesthetic,  35;  how  to 
administer,  41;  in  hypersensitive  den- 
tin, 160;  physiological  action  of,  34! 
mouth-prop  needed  in  administering, 
43;  with  oxygen,  41 

Normal  hemorrhage,  55 
salt  sokition,  49 

Nux  vomica  in  scrofula,  94 


Obstructed   ducts  in  neuralgia,   31 

Obstruction  to  breathing  contraindlcating 
anesthesia,  34;  treatment  of.  45 

Occupation  influencing  hysteria,  22 

Ocular  troubles  in  neuralgia,  31 

Oil  of  cloves  in  acute  pulpitis,  168 
of  wintergreen  in  rheumatism,  100 

Operations  during  pregnancy,  52;  under  an- 
esthesia, preparation  for,  42;  medi- 
cines, etc.,  needed  in  readiness  for,  42; 
under  local  anesthesia,  50 

Opiates  in  necrosis,  203 

Opium  in  difficult  dentition,  134;  in  hem- 
orrhage, 58,  60;  in  neuralgia,  32;  m 
salivation,  139 

Oral  fluids  in  dental  carles.  145;  in  dental 
erosion,  182 

Overwork  in  hysteria,  22 

Oxygen   with   chloroform,    41;    with    nitrous 

oxid,  36 

I» 

Pain,  character  of,  in  dento-alveolar  abscess, 
iSo;  dependent  upon  constipation.  61; 
how  induced  in  hypersensitive  dentin, 
153;  in  antral  disease,  209;  in  hyper- 
emia, 164;  in  inflammation,  character 
and  degree  of,  9;  in  neuralgia,  29;  in 
necrosis,    200;    in    pericementitis,    176; 


236 


INDEX. 


Pain — 

in  phagedenic  pericementitis,  124;  pos- 
ture influencing,  10;  in  pulp  nodules, 
194 

Paraplegia  in  difficult  dentition,  129 

Partial  anesthesia  a  source  of  danger,  45 

Patches,  removal  of,  in  stomatitis,  74 

Pathological  processes,  influence  of,  2; 
knowledge  of,  as  a  basis  of  treatment,  2 

Pathology,  definition  of,  i ;  general  consid- 
erations in,  I 

Pericementitis,  174;  antikamnia  in,  177;  arti- 
ficial sinus  in,  177;  calculi  in,  175; 
cathartics  in,  177;  chronic  form  of, 
176;  constitutional  symptoms  of,  176; 
counter-irritation  in,  176;  death  of  the 
pulp  in,  174;  diagnosis  of,  176;  etiology 
of,  174:  foot-baths  a  remedial  measure 
in,  177;  in  neuralgia,  31;  leeches  in, 
176;  local  bloodletting  in,  176;  mal- 
occlusion causing,  175;  pain  in,  176; 
pathology  of,  175;  pressure  of  gases 
causing,  175  ;  pressure  of  inflammator>- 
products  causing,  175 ;  sensitiveness  of 
teeth  to  percussion  in,  175;  sodium 
bromid  in,  177;  symptoms  of,  175; 
synonyms  of,  174;  tincture  of  aconite 
root  in,  177;  tincture  of  iodin  in,  177; 
treatment  of,  176 

Pericementum  affected  in  dento-alveolar  ab- 
scess, 178 

Periosteum  destroyed  in  necrosis,  200;  loss 
of,  in  dento-alveolar  abscess,   179 

Peroxid  of  hydrogen  in  diagnosis  of  antral 
disease,  211 

Phagedenic  pericementitis,  122;  acute  form 
of,  123;  campho-phenique  in,  125;  con- 
stitutional treatment  of,  125;  definition 
of,  122;  deposits  in,  124;  destruction  of 
the  membrane  in,  i2|;  looseness  of  the 
teeth  in,  124;  micro-organisms  in,  122; 
pain  in,  124;  pockets  in,  124;  replanta- 
tion in,  125;  sponge-grafting  in,  125; 
zinc  chlorid  in,  125 

Phagocytosis,  18 

Phantom  tumors  in  hysteria,  25 

Phosphor-necrosis,   196 

Plates  swallowed,  62 

Position  of  the  body  in  hemorrhage,  58 

Posture  influencing  hemorrhage,  61;  influ- 
encing pain,  10;  influencing  syncope, 
20 

Potassium  bromid  in  tetanus,  108;  in  diffi- 
cult dentition,  133 
chlorate  in  stomatitis  herpetica,  74;  hy- 
phomycetica,  78;  gangraenosa,  82; 
ulcerosa,  80;  in  salivation,  139 
iodid  causing  gingivitis,  109;  in  neu- 
ralgia, 31;  in  rheumatism,  99;  sulpho- 
cyanid  in  dental  erosion,   183 


Predisposing  cause,  definition  of,  4 

Pregnancy,  52;  a  physiological  process,  52;: 
anesthetics  during,  53;  effect  of,  on- 
general  system,  52;  on  nervous  sys- 
tem, 54;  saliva  in,  54;  teeth  in,  54;  in. 
relation  to  dental  caries,  146;  opera- 
tions during,  52;  possible  results  of 
operations  during,  53;  stage  of  anes- 
thesia in,  S3;  treatment  of  mouth  dur- 
ing, 54;  use  of  sedatives  in,  52 

Preliminary  stage  of  anesthesia,  45 

Pressure  in  hemorrhage,  58 

Prevention  of  scurvy,  90 

Preventive  treatment  in  hemorrhage,  57 

Primary  stage  of  ether  anesthesia  for  short 
operations,  44 

Ptyalism,  cause  of  salivary  fistula,  136 

Puerperal  tetanus,  103 

Pulp,  changes  of,  in  abrasion,  188;  en- 
croachment upon,  in  secondary  den- 
tin, 192;  irritation  of,  in  neuralgia,  29;^ 
removal  of,  in  pulp-nodules,  195;  vital- 
ity of,   in  hypercementosis,   189 

Pulp-nodules,  193;  carbolic  acid  in  treat- 
ment of,  195;  causal  irritations  in,  19^^ 
cocain  in,  195;  definition  of,  193;  etiol- 
ogy of,  193;  history  in,  193;  location 
and  size  of,  194;  manner  of  calcifica- 
tion of,  193;  pain  in,  194;  pathology  of, 
194;  removal  of  the  pulp  in,  195;  symp- 
toms and  diagnosis  of,  194;  teeth  most 
frequently  aft'ected  in,  194;  treatment 
of,  195 

Pulp-stones  in  neuralgia,  29 

Pulpitis,  acute,  165;  abrasion  causing,  165; 
capping  pulps  in,  168;  carbolic  acid  in, 
168;  caries  causing,  165;  diagnosis  of, 
167;  erosion  causing,  165;  etiology  of, 
165;  exposure  of  pulp  in,  166;  hyper- 
emia in,  166;  illustration  of,  167;  in- 
flammatory process,  166;  oil  of  cloves 
in,  168;  pain  in,  166;  pathology  of,  166; 
removal  of  filling  in  treatment  of,  168; 
symptoms  of,  166;  thermal  changes 
causing,  165 ;  tincture  of  aconite  in, 
168;  treatment  of,  167 
chronic,  169;  hypertrophy  of  tissue  in, 
169 

Pulse  in  inflammation,  12 

Purpose  of  cell-migration,  18 

Pus,  18;  causing  pyorrhea,  115;  escape  of, 
in  dento-alveolar  abscess,  178;  in  ab- 
scess of  the  pulp,  171 ;  in  antrai  disease, 
210;  in  necrosis,  199 

Putrescent  fluid  in  blood,  3 

Pyogenic  organisms  in  abscess  of  the  pulp, 
171 

Pyorrhea  alveolaris,  no;  absorption  and 
necrosis  in,  119;  acid  solvents  in  treat- 
ment of,  120;  alveolar  process,  destruc- 


IXDEX. 


^Z7 


Pyorrhea  alveolaris  — 

tion  of,  119;  appliance  for  supporting 
loose  teeth  in,  122;  breath  affected  in, 
119;  calculary  deposits  in,  iii;  calculi 
in,  analysis,  n6;  calculi  in,  varieties, 
112,  113;  calculus  in,  how  found,  in; 
catarrh,  significance  in,  114;  composi- 
tion of  oral  fluids  in,  in;  constitu- 
tional diathesis  causing,  117,  118;  dia- 
betes causing,  118;  duration  of,  120; 
effect  of,  119;  glands  in,  abnormal  ac- 
tion of,  112;  glands  secreting  oral  fluids 
in,  in;  gouty  calculi  in,  114;  gums, 
color  in,  118;  hematogenic  calcic  peri- 
cementitis one  form  of,  116;  kidney 
disease  causing,  116;  local  and  consti- 
tutional relations  of,  117;  micro-organ- 
isms in,  112!  nitrate  of  silver  in,  122; 
origin  of  calculi  in,  116;  physical  ex- 
amination necessary  in,  115;  ptyalo- 
genic  calcic  pericementitis  one  form 
of,  116;  pus  causing,  115;  pyrozone  in, 
121 ;  quinin  sulfate  in,  121 ;  removal  of 
deposit  in,  120;  replantation  in,  122; 
sodium  bicarbonate  in,  121 ;  symptoms 
of  other  diseases  in,  115;  synonyms, 
no;  tartar  causing,  115;  tincture  of 
catechu  in,  121;  warm  spray  in,  121 

Tyrozone  in  pyorrhea,  121 


Quiet  in  tetanus,  108 

■Quinin  in  neuralgia,  31;  in  pyorrhea,  121;  in 
rheumatism,   99 

1% 

Ra.nula,  age  in,  140;  calcareous  formations 
in,  141;  diagnosis  of,  142;  etiology  of, 
140;  excision  of,  142;  extirpation  of, 
1+2;  general  health  in,  141;  illustrative 
cases  of,  142;  pathology  of,  141;  prog- 
nosis of,  142 ;  rapid  progress  of,  141 ; 
seton  in,  142;  swelling  in,  141;  symp- 
toms of,  141;  treatment  of,  142;  tumor 
formation  in,   141;  zinc  chlorid  in,   142 

Reflex  irritation  in  difficult  dentition,  12S, 
129 

Relation  of  adenoid  growths  to  irregulari- 
ties of  the  teeth,  221 ;  to  act  of  swal- 
lowing, 223;  to  asymmetrical  deformi- 
ties, 223;  to  dropping  of  lower  jaw  in 
mouth-breathing,  224;  to  hard-palate 
deformities,  222;  to  Hutchinsonian 
teeth,  227;  to  mouth-breathing,  221;  to 
normal  arches,  226;  to  pressure  of  tis- 
sues against  the  teeth,  225;  to  thumb- 
sucking,  227 

Removal  of  clot  in  hemorrhage,  58 

Replantation  of  teeth  in  phagedenic  peri- 
cementitis,  125;   in  pyorrhea,   122 


Respiratory  organs  in  tetanus,   105 

Rest  in  tetanus,  108 

Rhachitis,  91;  calcification  imperfect,  91; 
climate,  91;  cod-liver  oil  in,  92;  defini- 
tion of,  91;  effect  of,  on  teeth,  91; 
etiology  of,  91 ;  heredity  in,  91 ;  hygiene 
in,  92;  hypophosphites  of  lime  and 
soda  in,  92;  iron  in,  92;  irregulari- 
ties of  teeth  in,  91;  pathology  of,  91; 
retarded  dentition  in,  91  ;  symptoms 
of,  91 ;  synonyms  of,  91 ;  treatment  of, 
92 

Rheumatic  condition  in  scurv}',  87 

Rheumatism,  acute,  98;  age  in,  98;  atmo- 
sphere in  relation  to,  98;  definition  of, 
98;  digestive  organs  affected  in,  98; 
etiology  of,  98;  heredity  in,  98;  joints 
aft'ected  in,  98;  muscles  affected  in,  98; 
symptoms  of,  98;  synonyms  of,  98; 
temperature  in,  98 
chronic,  98;  arsenic  in,  99;  cod-liver 
oil  in,  99;  definition  of,  98;  diagnosis 
of,  99;  diet  in,  99;  erosion  of  the 
teeth  in,  99  ;  hvgiene  in,  99;  iodid 
of  iron  in,  99;  lithium  in,  100;  oil  of 
wintergreen  in,  100;  quinin  in,  99; 
sodium  salicylate  in,  99;  symptoms  of, 
99;  treatment  of,  99;  water,  use  in,  99 

Rhubarb  in  difficult  dentition,  134 

Richardson's  case  of  gastrotomy,  63 

Robinson's  remedy  in  hypersensitive  den- 
tin,  157 

Roe's  case  of  esophagotomy,  65 

Roentgen  ray  in  discovering  foreign  bodies 
swallowed,  66 

Saliva  affected  during  pregnancy,  54; 
hyperacidity  of,  in  dental  erosion,   182 

Salivary  calculus  in  neuralgia,  31 

fistula,  135;  definition  of,  135;  dura- 
tion of,  136;  etiology  of,  135;  illustra- 
tive cases  of,  137;  nitrate  of  silver  in, 
136;  operation  for,  136;  ptyalism  caus- 
ing, 136;  symptoms  of,  136;  treatment 
of,   136 

Salivation,  138;  fetid  breath  in,  139;  car- 
bolic acid  in,  140:  catechu  in,  140;  defi- 
nition of,  138;  diagnosis  of,  \\2;  dis- 
ease causing,  138;  duration  of,  139; 
etiology  of,  138;  face  and  neck  affected 
in,  139;  Goulard's  extract  in,  140;  gums 
affected  in,  139;  opium  in,  139;  pathol- 
ogy of,  13S;  potassium  chlorate  in, 
139;  prognosis  of,  142;  Seidlitz  powder 
in,  140;  stomatitis  causing,  138;  symp- 
toms of,  139;  teeth  affected  in,  139; 
tongue  affected  in,  139;  treatment  of, 
139;  trichloracetic  acid  in,   140 

Scar  tetanus,  104 


238 


INDEX. 


Schleich's  mixtures,  39;  solutions  of  cocain, 

Scrofula,  92;  acquired,  92;  age  in  relation 
to,  93;  cod-liver  oil  in,  94;  definition 
of,  92;  its  effect  on  certain  dental  dis- 
eases, 94;  its  effect  on  the  teeth,  93; 
etiology  of,  92;  heredity  in,  92;  hy- 
giene in,  94;  nux  vomica  in,  94;  its 
relation  to  syphilis,  93;  symptoms  of, 
93;  synonyms  of,  92;  transmission  of, 
92 

Scrofulous  diathesis  causing  adenoid  dis- 
ease, 217;  causing  hypertrophy  of  ton- 
sils, 214;  in  catarrhal  stomatitis,  68 

Scurvy,  85;  appetite  in,  87;  atmosphere  in, 
85;  calomel  in,  88;  cow's  milk  in,  88; 
definition  of,  85;  diagnosis  of,  88;  eti- 
ology of,  85;  exhaustion  in,  85;  gingi- 
vitis confounded  with,  lop;  grape-juice 
in,  86;  illustrative  case  of,  89;  lemon- 
juice  in,  86;  mental  condition  in,  85; 
pathology  of.  86;  prognosis  of,  88; 
rheumatic  condition  in,  87;  skin  in, 
87;  symptoms  of,  87;  synonyms  of,  87; 
swelling  of  gums  in,  88;  teething  in, 
87;  temperature  in,  85;  treatment  of, 
88;  vegetable  food  in,  85 

Season  in  inflammation,  6 

Secondary  dentin,  192;  color  of  new  growth 
in,  192;  definition  of.  192;  formation 
of  dentinal  canals  disturbed  in,  192; 
location  of  deposit  in,  192;  pathology 
of,  192 
hemorrhage,  55,  58 

Secretions,  examination  of,  in  dental  ero- 
sion, 184,  185 

Seidlitz  powder  in  salivation,  140 

Septa  in  antral  chamber,  212 

Seton  in  ranula,  142 

Sex  in  hysteria,  22 

Shock  in  hj'steria,  22 

Silver  nitrate  in  dental  caries,   152 

"Skimmed  milk  cure"  in  gastritis,    ic2 

Skin  in  scurvy,  87 

Sleep  in  neuralgia,  32 

Sodium  bicarbonate  in  difficult  dentition, 
134;  in  hypersensitive  dentin,  159;  in 
pregnancy,  54;  in  pyorrhea,  121 
bromid  after  anesthesia,  47;  in  difficult 
dentition,  133;  in  hysterical  conditions, 
2.T,  in  hypersensitive  condition,  160;  in 
pericementitis,  177 
salicylate  in  rheumatism,  99 

Sounding  in  diagnosis  of  antral  diseases,  211 

Sponge-grafting  in  phagedenic  pericemen- 
titis, 125 

Stages  of  anesthesia,  45 

Stimulants  in  heart  failure,  46;  in  diph- 
theria, 84 

Stomata  in  vessel  walls,  16 


Stomatitis  causing  salivation,  138;  classifi- 
cation of,  67 

catarrhal,  67;  age  in,  67;  antiseptic 
wash  in,  71 ;  bacteria  in,  68;  cleanli- 
ness in,  70;  diagnosis  of,  69;  duration 
of,  69;  eruption  of  the  teeth  in,  68; 
etiology  of,  67;  fever  in,  69;  food  m, 
70;  lack  of  cleanliness  in,  68;  nitrate 
of  silver  in,  70;  parts  involved  in,  68; 
pathology  of,  68;  prognosis  of,  69; 
secretions  in,  68;  scrofulous  diathesis 
in,  68;  symptoms  of,  69;  synonyms  of, 
dy;  treatment  of,  70;  tongue  in,  69 

gangrenosa,  81 ;  constitutional  treatment 
of,  82;  definition  of,  81;  destruction  of 
tissue  in,  82;  etiology  of,  81;  micro- 
organisms in,  81 ;  pathology  of,  81 ; 
potassium  chlorate  in,  82;  prognosis 
of,  82;  skin  in,  appearance,  81;  symp- 
toms of,  81 ;  synonyms  of,  81 ;  treat- 
ment of,  82 

herpetica,  71;  age  in,  71;  astringents  in, 
74;  constitutional  symptoms  of,  73; 
ccnstitutional  treatment  cf,  78;  cul.ure- 
test  in,  74;  diagnosis  of,  73;  etiology 
of,  71;  location  of  lesions  in,  .72; 
pathology  of,  71 ;  potassium  chlorate 
in,  74;  prognosis  of,  73;  symptoms  of, 
Ti\  synonyms  of,  71;  treatment,  74 

hyphomycetica,  74;  abrasions  in,  75; 
brandy  and  water  in,  78;  cod-liver  oil 
in,  78;  constitutional  treatment  of,  78; 
diagncs's  of,  ■/■/;  etiology  of,  74;  fluids 
of  the  mouth  in,  75;  food  in,  78;  mode 
of  propagation  of,  76;  mold  fungi  in, 
74;  parts  affected  in,  76;  patches  re- 
moved in,  78;  pathology  of,  76;  potas- 
sium chlorate  in,  78;  predisposing 
bodily  condition  in,  75;  prognosis  of, 
yy;  symptoms  of,  77;  synonyms,  74; 
treatment  of,  77 

ulcerosa,  79;  cancrum  oris  compared 
with,  79;  constitutional  treatment  of, 
80;  definition  cf,  79;  diagnosis  of,  80; 
duration  of,  79;  etiology  of,  •]<)■,  isola- 
tion in,  80;  pathology  of,  79;  prog- 
nosis of,  80;  prophylaxis  in,  80;  symp- 
toms of,  79;  treatment  of,  80;  trichlor- 
acetic acid  in,  80 
Suggestion    in    hypersensitive    dentin,     154, 

160;  in  inducing  anesthesia,  43 
Sunshine  in  neuralgia,  'iz 

Suppuration  of  the  pulp,  170;  bacteria  in, 
mode  of  entrance  to  pulp,  171;  carbolic 
acid  in,  174;  cold  and  heat  tests  in, 
174;  definition  of,  170;  etiology  of,  171; 
formalin  in,  174;  illustrations  of  ab- 
scess of  pulp,  172,  173;  illustration  of 
suppuration  of  pulp,  172,  173;  pain  in, 
174;  parts  first  affected,  171;  pathology 


INDEX. 


239 


Suppuration  of  the  pulp  — 

of,  171;  prognosis  of,  174;  pus  in,  171; 
pus  evacuation  in,  174;  pyogenic  or- 
ganisms in,  171;  symptoms  of,  174; 
treatment  of,   174 

Susceptibility  during  pregnancy,  52 

Swallowing,  act  of,  its  effect  on  the  heart  in 
syncope,  20 
foreign  bodies  in  anesthesia,  46;  treat- 
ment, 46 
plates  and  other  foreign  bodies,  62;  cases 
oi,  63  ( — Gardner's  case,  63;  — Gooch's 
case,  64;  — Leach's  case,  63;  — Rich- 
ardson's case,  63;  — Roe's  case,  65; 
^Signer  Ranana,  64;  — Velpeau's  case, 
65;  — Wilson's  case,  66);  caution  as  to 
wearing  partial  dentures,  66;  caution 
as  to  replacing  clasps,  66;  food  in 
treatment  of  cases  of,  66;  gastrotomy 
in  cases  of,  63;  treatment  of  cases  of, 
66;  X  rays  in  cases  of,  66 

Swelling  in  antral  disease,  209;  in  inflam- 
mation, ID,  13;  ( — amount,  10;  — causes, 
13;  — frequency,  10;  — occurrence  in 
certain  structures,  10) ;  in  ranula,  141 

Sympathetic  relations,  2;  in  difficult  denti- 
tion, 127 

Sympathy  in  hysteria,  22 

Symptomatology,   i 

Symptoms,  groups  of,  i ;  how  made  known, 
I ;  use  of,  I ;  objective,  i ;  abnormal 
products  producing,  2;  affected  nerves 
causing,  2 
of  inflammation,  9;  classification  of,  g; 
constitutional,  11;  local,  9;  discolora- 
tion, 8;  disordered  function,  11;  heat, 
10;  pain,  9;  swelling,  10 

Syncope,  20;  definition  of,  20;  etiology  of, 
20;  treatment  of,  20 

Syphilis,  95;  diagnosis  of,  97;  effects  of,  on 
the  teeth,  97;  etiology  of,  96;  modes 
of  infection  in,  96;  nature  and  course 
of,  95;  period  of  invasion  in,  95;  rela- 
tion of,  to  scrofula,  93;  secondary 
stage  of,  96;  second  period  of  incuba- 
tion of,  95;  symptoms  of,  96;  tertiary 
period  of,  97;  treatment  of,  97 

T 

Tannin  in  hemorrhage,  58 
Tartar  causing  pyorrhea,  115 
Tartarlithine  in  dental  erosion,   187 
Teeth    affected    by    syphilis,    97;    by    saliva- 
tion,  139;   containing  bacteria,   102;  af- 
fected during  pregnancy,  54;   effect  of 
gastritis    upon,    102;    extraction    of,    in 
neuralgia,  29 ;  eruption  of,  in  catarrhal 
stomatitis,  68;  in  rhachitis,  91;  lack  of, 
in  relation  to  gastritis,  103;  perforating 
the  antrum,  208 


Temperature  in  diphtheria,  83;  in  difficult 
dentition,  129;  in  inflammation,  12;  in 
scurvy,  85 

Tender  spots  in  neuralgia,  29 

Termination   of  inflammation,   modes  of,    19 

Tetanus,  103;  acute,  103;  antitoxin  in,  107; 
bacillus  tetani  in,  104;  bacteriological 
examinations  in,  107;  chronic,  103;  con- 
stitutional treatment  of,  108;  defini- 
tion of,  103;  diagnosis  of,  106;  dura- 
tion of,  105;  etiology  of,  103;  ether 
in,  108;  experiments  upon  animals 
with  bacillus  of,  105;  facial  expression 
in,  105;  hydrophobia  compared  with, 
106:  hydrophobicus,  103;  hysterical 
contraction  of  muscles  in,  106;  intra- 
cerebral injections  in,  107;  jaws,  con- 
dition in,  105;  lesion  of  the  skin  essen- 
tial in,  104;  morphin  in,  108;  muscles 
of  the  neck  in,  105;  potassium  bromid 
in,  108;  prognosis  of,  106;  punctured 
wounds,  significance  in,  104;  quiet  in, 
108;  respiratory  organs  in,  105;  rest 
in,  108;  saliva  in,  105;  "scar-,"  104; 
serum,  large  quantity  necessary  in 
treatment  of,  108;  skin  in,  105;  spinal 
meningitis  in,  106;  stiffness  of  jaw  in, 
106;  strychnin  poisoning  compared 
with,  106;  symptoms  of,  105;  tetany 
distinguished  from,  106;  the  mind  in, 
105;  treatment  of,  106;  trismus  nascen- 
tium  a  variety  of,  103;  varieties  of, 
103;  urine  in,  108;  warmth  in,  108 
bacillus,  where  found,  104;  properties  of, 
104 

Thermal  changes  in  hyperemia  of  pulp,  162; 
in  acute  pulpitis,  165 

Thumb-sucking,  effect  of,  227 

Tincture  of  catechu  in  gingivitis,  no 

Tongue  in  salivation,  139;  in  inflammation, 
12 

Tonsils  in  inflammation,  10 

Tracheotomv  for  foreign  bodies  swallowed, 
66 

Transillumination  in  antral  disease,  210,  211 

Traumatic  inflammation,  7 

Treatment,  basis  of,  2;  analysis  of  secre- 
tions in,  2;  first  considerations  in,  2; 
inspection  of  parts  and  organs  in,  2 

Trichloracetic  acid  in  ulcerative  stomatitis, 
80;   in  salivation,   140 

Tuberculosis  causing-  ankylosis  of  the  jaw, 
206;   contraindicating   anesthesia,   34 

Tuberculous   diathesis   in  hysteria,  21 

XJ 

Unfavorable   conditions   during  and  after 

anesthesia,  45 
Uric   acid   diathesis   in   relation  to   enlarged 

tonsils,  214 
Uterus,  relation  of,  to  hysteria,  22 


240 


INDEX, 


Valerian-ate  of  ammonium  in  hysteria,  27 
Vaselin,  for  anointing  the  face  previous  to 

administering-  ether,  44 
Vegetable  food  in  scurvy,  85 
\'elpeau's  case  of  swallowing  a  fork,  65 
\'eratria   in   hypersensitive   dentin,    157 
\'icarious  menstruation,  52 
^'oice  indicating  adenoid  disease,  218 

^^'ARM  air  in  hypersensitive  dentin,  method 

of  applying,  155 
\\'armth  in  tetanus,  108 
^^'atchfulness  in  idiosyncrasy,  4 


Water  in  treatment  of   constipation,   62;   in 
hysteria,  27;  in  rheumatism,  99;  in  syn- 
cope, 20 
Wax  in  treatment  of  hemorrhage,  59 
White    blood-cells,    abnormal    condition    of, 
3;     attraction    and    repulsion     of,     18 
beneficent  action  of,   18;  migration  of 
13;   modification  of,    18;   normal  condi 
tion    of,    3;    phagocytic    action    of,    3 
subdivision  of,  19 


Zinc  chlorid  in  hypersensitive  dentin,  155, 
156;  in  phagedenic  pericementitis,  125; 
in  ranula,  142 


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